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ESSAYS ON 
LABOR J TOR Y DIAGNOSIS 

—FOR THE— 

GENERAL PRACTITIONER 



BY 



HENRY R. HARROWER, M. D. 

Professor of Clinical Diagnosis, Bennett Medical College 

(Medical Department Loyola University); Editor, "The 

American Journal of Physiologic Therapeutics", 

Member, American Medical Association, 

American Association for Medical 

Research, Tri-State Medical 

Society, Etc., Etc. 




CHICAGO 

NEW MEDICINE PUBLISHING CO. 

1911 



# 



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V 



Copyright!; 1911 

BY 

HENRY R. HARROWERJM. D. 



ENTERED AT STATIONERS HALL, LONDON 



ALL RIGHTS^ RESERVED 



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TABLE OF CONTENTS. 

PAGE 

Preface 13 

Introduction — By W. F. Waugh, A.M., M.D . 17 

Chapter I. — The Laboratory as a Means of Pro- 
moting Professional Proficiency 23 

(Medical World, November, 1908.) 

Chapter II. — The Importance of Laboratory 

Methods 29 

(Chicago Clinic, June, 1909.) 

Chapter III. — Success in the Treatment of Chronic 
Disease 35 

(American Medicine, February, 1910.) 

Chapter IV. — An Important Element of Success in 

the Treatment of Chronic Diseases 47 

(Medical Standard, October, 1909.) 

Chapter V. — Mysticism and Medicine 57 

(Medical Standard, March, 1910.) 

Chapter VI. — The Advantages of the Urine Ex- 
amination 65 

(Milwaukee Medical Journal, December, 1909.) 

Chapter VII. — Prophylactic Laboratory Work 73 

(Medical Standard, June, 1910.) 

Chapter VIII. — Routine Urine Examinations 77 

(New York Medical Journal, Feb. 27, 1909.) 



10 Table of Contents 

PAGE 

Chapter IX. — A New Instrument for the Estima- 
tion of the Urinary Acidity 83 

(New York Medical Journal, Jan. 2, 1909.) 

Chapter X. — A Study of the Urinary Acidity and 

Its Relations 89 

(Medical Record, June 5, 1909.) 

Chapter XL — Acidemia and Autointoxication 109 

(American Medicine, January, 1909.) 

Chapter XII. — Acidemia: Systemic Hypo-Alka- 
linity 115 

(Medical Brief, August, 1910.) 

Chapter XIII. — The Relations and Clinical Sig- 
nificance of the Urinary Acidity 127 

(Illinois Medical Journal, October, 1910.) 

Chapter XIV. — The Urinary Ammonia in Routine 
Work 141 

(Medical Council, January, 1911.) 

Chapter XV. — The Collection of the Urinary 
Specimen 153 

(Medical Standard, September, 1909.) 

Chapter XVI.— Low Total Solids : Its Treatment 161 
(General Practitioner, December, 1910.) 

Chapter XVII. — What the Urine Report Means. . 169 
(Clinical Medicine, August, 1909.) 

Chapter XVIII. — The Therapeutic Indications of 

the Urinalysis 187 

(Clinical Medicine, October, 1909.) 



Table of Contents 11 

PAGE 

Chapter XIX. — Laboratory Help in Tuberculosis . . 197 
{Clinical Medicine, July, 1909.) 

Chapter XX. — The Urine in Tuberculosis 205 

{Medical Standard, April, 1910.) 

Chapter XXI. — Conclusive Researches in Meta- 
bolism 215 

{Lancet-Clinic, Nov. 12, 1910.) 

Chapter XXII. — Indican from the Standpoint of 

the General Practitioner 225 

{American Medicine, December, 1910.) 

Chapter XXIII. — Indicanuria and Enteroptosis . . . 241 
{Physiologic Therapeutics, May, 1910.) 

Chapter XXIV. — The Value of the Urinalysis in 
Dermatology 249 

{American Journal of Dermatology, May, 1909.) 

Chapter XXV. — The Life Insurance "Urine Exam- 
ination" — A Farce 257 

{American Medicine, October, 1909.) 

Chapter XXVI. — Metabolism and Mouth-Disease. 265 
{The Journal of the Amer. Med. Ass'n, Oct. 1, 1910.) 

Chapter XXVII. — The Importance of the Clinical 

Laboratory in Surgery 273 

{American Journal of Surgery, October, 1910.) 

Chapter XXVIIL— The Twenty-Five-Dollar Office 
Laboratory 283 

{Medical World, March, 1911.) 



PREFACE. 

"There is nothing new under the sun/' nor is there 
anything new in this book, but several important facts 
which seem to have been somewhat overlooked in the 
past are reiterated here because, as the venerable physi- 
cian and educator, A. Jacobi, has well said: "Simple 
truths in practical medicine do not merely bear repetition 
— they require it." 

To find laboratory work done by the general prac- 
titioner, is the exception rather than the rule. To find 
any physician who is in the habit of making a thorough 
investigation of the metabolic functions of every patient 
seeking his aid, is almost impossible. He does not see the 
need for it and "the patient won't stand for it." And 
yet every disease either affects, or is affected by, the way 
in which the vital interchanges take place. 

I have tried, in the papers which are reprinted here, 
to accomplish three things : First, to stimulate a greater 
interest in the actual need for clinical laboratory work 
by the physician in his otirn office; second, to simplify 
certain phases of this work; third, to cause, as best 
I can, a better understanding of the actual laboratory 
findings, and to make the therapeutic ends to which they 
point as clear and plain as possible. The attempt has 
been, on the whole, to lead rather than to teach. 

One unfortunate circumstance which has often 



14 Essays on Laboratory Diagnosis 

impressed me is that when an article has once appeared 
in print, it is read, appreciated, perhaps, and either laid 
aside or destroyed. Rarely is it at hand for convenient 
reference. From correspondence with hundreds of 
physicians in various parts of this country and abroad, 
I have been impressed that the majority of these 
articles are of some real help. This is encouraging. 
Hundreds of requests for reprints had to be denied sim- 
ply because they were not at hand. Hundreds more re- 
ceived reprints when I had them to give. But none 
received more than two or three reprints and many re- 
quests have finally caused me to venture the publication 
of this collection. 

No attempt has been made to make this either a 
hand-book or a text-book. The papers are republished 
with little or no changes. I am conscious of many short- 
comings, the principal among them being frequent rep- 
etition. I hope these will be overlooked. One corre- 
spondent explained away this excuse of mine for post- 
poning publication of the book by saying: "You know 
the truth can stand a whole lot of repetition." 

It is to be hoped that this little effort may continue 
to serve as a stimulus to practice more thorough and, 
consequently, more successful ftiedicine. 

Park Ridge, Illinois. 



INTRODUCTION. 

By William Francis Waugh, A. M., M. D., 

Dean and Professor of Therapeutics, Bennett Medical College, 
Chicago; Medical Department Loyola University; Editor 
"American Journal of Clinical Medicine," etc. 



INTRODUCTION. 

This little book is a praiseworthy attempt to stimu- 
late a greater interest on the part of the average physi- 
cian in the importance of utilizing clinical laboratory 
methods in his daily routine. Too many physicians are 
prone, even in these days of enlightenment, to consider 
that the urine examination is indicated only in suspected 
renal or bladder diseases. The importance of the urinary 
findings as a guide to the resistant powers of the body 
is all too frequently overlooked. 

Two generations ago disease was considered solely in 
its clinical aspect, and the aberrations from healthy func- 
tional activity formed the chief concern of the physician. 
As the study of pathologic anatomy progressed the basis 
of our conceptions of disease changed. We had been 
familiar with certain diseases as characterized by well- 
defined symptom-groups, and against these we had di- 
rected our therapeutics with considerable success. Dis- 
ease and its treatment were thus linked by observations 
extending over many centuries, with constant improve- 
ment as old superstition was replaced by modern sci- 
ence, old error eliminated by more precise methods of 
observation and reasoning. The new knowledge dimmed 
this picture, and replaced it by one in which the symp- 
toms of the living patient were obscured by the lesions 
discovered in the body of the dead. Too often it was 



18 Essays on Laboratory Diagnosis 

forgotten that we were then dealing with the end- 
results of the pathologic processes, with the ashes of a 
burned-out fire. 

No disease presents structural lesions at the start. 
All begin with disorders of the vital functions which, 
proceeding unchecked, result in such irritation some- 
where as to invoke organic disease with destructive alter- 
ations. Since these are very often beyond the reach of 
curative treatment, it is up to us to recognize these 
affections while as yet in the early stages of functional 
derangement, when a cure may be effected. This brings 
the physician back from the laboratory to the sick-room ; 
from the study of completed pathologic processes; from 
dead anatomy, to that of disordered vital function in 
the living body. It emphasizes the value of the proposi- 
tion that our best work is to be done before the patient 
is taken down with sickness. It urges the supreme 
value of preventive medicine as applied to the individ- 
ual. 

The value of the quantitative examination of the 
urine as a means of judging the state of the metabolism 
can only be ignored by him who has not learned the 
inestimable aid it affords to a correct diagnosis of the 
state of the physiologic functions. 

The diagnosis of disordered functions is of far 
greater therapeutic importance — at least as far as results 
are concerned — than the corroboration of the presence 
of some suspected organic disease. In the former, infor- 
mation is gained which can be used to great advantage; 
whereas, in the latter a belief is only strengthened and 



Introduction 19 

the possibilities of successful end-results dimmed. 

The times demand that the physician must earn his 
pay. He must be useful. He must be able to cope with 
disease or step aside for the other man. Diagnosis is 
but a preliminary, and if it does not point the way to 
effective treatment, it does not meet the needs of the 
situation. The science of medicine is supplemented by 
the art. 

Considerable stress has been laid by Doctor Har- 
rower upon the urinary acidity as a point of importance 
in diagnosis, and this is as it should be. The alkalinity 
of the blood is a factor of intense interest, since upon its 
variations the whole of the functions of the vital fluid 
depend. For these reasons I commend this useful little 
book to those for whom it has been prepared. 

Chicago, October, 1910. 



THE LABORATORY AS A MEANS OF PRO- 
MOTING PROFESSIONAL EFFICIENCY. 

Reprinted from 

THE MEDICAL WORLD, 
Philadelphia, 

November, 1908. 



CHAPTER I. 

THE LABORATORY AS A MEANS OF PRO- 
MOTING PROFESSIONAL EFFICIENCY. 

Every live medical man is continually on the look- 
out for something that will increase his efficiency. The 
crowded condition of the profession and the continual 
stream of new men from the many medical schools 
make it imperative for the progressive practitioner to 
increase his efficiency. He must get results. 

The periodical trip to Chicago, New York, or even 
to Europe for post-graduate study, the purchase of the 
latest and best medical books, the regular perusal of three 
or four good, live medical journals, and the attendance 
at the local medical society are all greatly conducive to 
better practice; but the continued use of the clinical 
laboratory will do more, perhaps, than any one thing to 
make for thorough and accurate work. 

With the majority of practitioners the sins of omis- 
sion are usually far greater than the sins of commission ; 
in other words, the average doctor of today errs more 
on the side of laxness than from the exhibition of an 
overplus of effort or enthusiasm in his attempts at care- 
ful diagnosis. 

Many a patient goes from one physician to another, 
at each change leaving his previous medical adviser 
slightly richer in dollars, but with a marked diminution 
of reputation. This is most unfortunate, for a reputa- 
tion cannot be measured in mere currency. 

It is well known that the American public is gullible 



24 Essays on Laboratory Diagnosis 

in the extreme — is easily duped. The huge sales of the 
hundreds of patent medicines and the success of the 
ever-increasing army of advertising quacks both testify 
to this. Yet it would seem a shame to say that many — 
so many — of the ethical, apparently sincere and consci- 
entious medical men are today doing nothing so very 
far removed from the deeds of the nostrum vendor or 
the charlatan. In these days of medical enlightenment, 
the physician still exists whose clinical examination con- 
sists of nothing more than the few perfunctory ques* 
tions, inspection of the tongue, and a fleeting touch of 
the pulse; but who, because of the influence gained by 
years of practice, still manages to make a more or less 
decent living. 

Let us make this a personal matter. Doctor, when 
Mrs. A. came into your office the other day complaining 
of that "tired feeling," and told of the headache, the 
pain in the side and back, the lack of energy, and the 
many other symptoms that we are constantly called 
upon to meet, did you ask for a specimen of the urine? 
Did you get a full 24-hour specimen and examine it 
carefully, finding out not only the specific gravity and 
whether albumin or sugar were present, but the acidity, 
urea, phosphates, indican, and so forth? Would not this, 
perhaps, have given you a little more light on the prob- 
lem? And when Mr. B. came to you with his story 
about his stomach, and how Dr. X. and Dr. Y. and even 
old Dr. Z. had treated him successively (but not suc- 
cessfully), did you emphasize the importance of a thor- 
ough examination, and a test-breakfast? Or did you 



Promoting Professional Proficiency 25 

just tell him that "fried foods are not so easily digested/' 
or "rapid eating is hard on the stomach/' give him some 
papayans or your favorite digestive what-not, and send 
him on his way to the next doctor to whom he might 
be recommended when your temporary relief ended? 

"But," you will say, "the people w r on't permit such 
examinations. You couldn't get them to pay for lab- 
oratory service." That may be; but you can, just the 
same, make it your definite routine practice with every 
case that comes to you for attention. It is true that 
your fees for clinical laboratory work may not all be 
paid, but the proportion will not be so very different 
from that of your other collections, some of which must, 
in due time, be marked down under "profit and loss." 

Or, again, the well-known excuse, "Oh! I haven't 
time to bother with that kind of work. I'm too busy/* 
Very true; but haven't you time to spend by the bed- 
side of the dangerously sick one, watching, working, 
and fighting hard, the crisis being near? You say, "Of 
course." Well, then, is not the treatment of the chronic 
and semi-chronic diseases, the lingering, nagging troubles 
that are all too common, as difficult in the end as the 
care of an acute case near the crisis? 

The practice of medicine is no easy matter. It may 
be very true that your well-stocked library and literature 
files can give you interesting and valuable information 
regarding therapeutics, but nothing save your own ef- 
forts will enable you to make the all-important diag- 
nosis. 

If the highly trained hospital expert with access to 



26 Essays on Laboratory Diagnosis 

so many interesting and complicated cases has to rely 
on laboratory assistance in his diagnostic work, must 
not such work be needful in your own practice? To- 
day's medical literature is simply teeming with articles 
demonstrating absolutely that accurate clinical methods 
are not only needful, but imperative. Can you afford 
to be behind the times ? 

Is not the reputation of being thorough and consci- 
entious well worth the time the few laboratory examina- 
tions may entail? Even though you may not be at all 
sure of a fee, is it not of sufficient value to you to know, 
and to know that you know? 

The small clinical laboratory has much in its favor; 
and I am thoroughly convinced that the money spent on 
equipment and the much-begrudged time spent at the 
actual work is the best investment that could be made. 
Osier has well said: "A room fitted as a small labora- 
tory, with the necessary chemicals and microscope, will 
prove a better investment in the long run than a static 
machine or a new-fangled air-pressure spray apparatus." 

The laboratory should be the backbone of the prac- 
tice of the general practitioner. It should occupy a place 
ranking equally with the other methods of precision 
in clinical diagnosis. It will bring you in contact with 
many persons whom you might otherwise never have 
met, and will enable you to see through cases that have 
baffled others. It will make for you a reputation for 
thoroughness and carefulness that cannot be compared 
in value with the time and money spent. The time 
spent in laboratory work will pay big dividends. 



II. 

THE IMPORTANCE OF LABORATORY 
METHODS. 

Reprinted from 

THE CHICAGO CLINIC, 
Chicago, 

June, 1909. 



CHAPTER II. 

THE IMPORTANCE OF LABORATORY 
METHODS. 

Laboratory work as an adjunct measure in both 
the diagnosis and treatment of disease is an essential, 
if success is expected in the practice of medicine. The 
laboratory alone is not infallible, supplanting the well- 
tried methods of precision and skill of the trained eye, 
ear, or finger tip of the diagnostician; but no matter 
how skilled the man, nor how valuable the methods, 
without laboratory aid he will certainly fail many times 
when a few simple facts, easily and quickly obtained 
in the laboratory, would have served to clear up the 
whole matter. 

In this progressive age the physician cannot consci- 
entiously practice medicine without frequent recourse 
to the all-important laboratory report. The facts so 
necessary in the routine work are by no means so diffi- 
cult to obtain, nor is the time and skill required for this 
work as serious a drawback as it is supposed by some 
to be. New methods and modifications of old ones have 
simplified the work so that it is now possible for the 
busy physician to carry out in his own office the major- 
ity of the tests necessary in this work. 

The examination of the urine cannot be given too 
much prominence in an article of this kind. It is a 
procedure that should be carried out in the investigation 
of every case consulting the physician. An erroneous 



30 Essays on Laboratory Diagnosis 

impression seems to be quite common among the laity 
and even some physicians that the urine is only exam- 
ined when diabetes or Bright's disease are suspected. 
No greater mistake could be made. If this were true, 
how are the insidious beginnings of the above-mentioned 
conditions to be detected? Unfortunately, many times, 
the harm is almost irretrievable before the patient is 
aware of his danger. It is an indisputable fact that 
in many hundreds of cases the onset of serious organic 
trouble might have been detected early, provided every 
case consulting the physician, no matter for what trouble, 
had been put through an exhaustive and routine exam- 
ination which included as a component part the complete 
analysis of a twenty-four-hour specimen of urine. In 
his excellent work on diagnosis, Leube says : "I would 
advise particularly never to omit the examination of the 
urine in headache; we shall thus avoid subsequent self- 
reproach." 

From an editorial in the Southern Medical Journal 
for April, 1909, I quote: "If the general practitioners 
would avail themselves of these methods of decision 
coming from chemical laboratories and microscopical 
findings, few cases of illness would go undiagnosed, and 
few sufferers lose the benefits of modern medicine." 
Again: "He is blind indeed who can have the aid of 
these modern laboratory methods and will not avail him- 
self of them, strictly as aids and confirmatory evidences 
of correct bedside judgment." 

Space will not be taken here to enter into a discussion 
of the importance of the other laboratory methods of 



Importance of Laboratory Methods 31 

decision. Every case evidencing gastric disturbance 
should be given a test meal and a careful examination 
of it should be made. In this way the exact conditions 
present in many chronic disturbances of the stomach 
and intestines could be appreciated and steps taken to 
arrest them. The unpleasantnesses so common when 
dissatisfied individuals suffering from chronic stomach 
troubles go from one physician to another, receiving 
some digestive tablets or other, and maybe a cathartic, 
and are, of course, only temporarily relieved, could be 
entirely avoided, at least in the majority of cases, by 
recourse to the gastric analysis. 

It is well known that many conditions which are 
either malignant or on the border line, so modify the 
condition of the blood that the examination of the blood 
smear gives information that will make the whole case 
clear. Again, the fecal examination is a valuable pro- 
cedure, which, unfortunately, is rarely made because of 
the unpleasant features and the inconvenience, but which, 
nevertheless, gives many valuable therapeutic pointers. 
The value of the report of the bacteriologist on a suspi- 
cious discharge, a throat membrane, or from a specimen 
of suspected tuberculous sputum will not be questioned. 
Therefore, since the methods mentioned above are all 
essential in the procedures necessary for making a cor- 
rect diagnosis, it is of the greatest importance that the 
laboratory should be far more frequently used by the 
general practitioner. 

In closing, I feel that I cannot too strongly impress 
tke fact that the laboratory report is of immense im- 



CHAPTER III. 

SUCCESS IN THE TREATMENT OF CHRONIC 
DISEASE. 

The average general practitioner is not, as a rule, 
especially overjoyed when an individual with some dis- 
ease of long standing comes his way seeking treatment. 
Most persons suffering from the class of diseases 
grouped under the broad term ''chronic/" have gone 
the rounds of the physicians in the neighborhood, and 
perhaps elsewhere, and have received little or no lasting 
benefit. If the physician expects to make a success 
in the treatment of these difficult conditions, a number 
of important maxims must be learned, and learned well. 
It will be my endeavor here to impress a few of these 
ideas upon the mind of the reader and in this way enable 
him to carry out with much greater success the treatment 
of chronic disease. 

Since a correct diagnosis is usually more than half 
the battle, it stands to reason that the time and trouble 
given to the investigation of a given case are time and 
trouble well spent. If a physician fails in the treatment 
of any chronic affection, assuming that that particular 
case is not absolutely "incurable" (and, fortunately, there 
are very few conditions met by the progressive medical 
man that are entirely beyond his skill), the fault is to be 
found either in his investigation or his therapeutic acu- 
men. Most frequently errors or shortcomings are in the 
diagnosis rather than the treatment, for the great and 



36 Essays on Laboratory Diagnosis 

ever-increasing progress in medical science, especially 
along lines of treatment, is all duly chronicled in the 
various medical journals, and in this way is just as avail- 
able for the physician at the remote country cross-roads 
as for the; city physician with his medical society meet- 
ings and clinics — if they both read. On the other hand, 
while it is granted that there are many books and ar- 
ticles of special informative value to the man who is 
anxious to increase his diagnostic skill, there is, of 
course, no book or article that will tell just what is 
the matter with Mr. Brown or Mrs. Jones. 

Successful work naturally entails close personal in- 
vestigation, and unless more than the ordinary attention 
is given to this most important part of medical practice 
the results, or lack of results, must necessarily be un- 
pleasant and unsatisfactory, both from the standpoint 
of the patient and of his physician. I might cite dozens 
of cases which have come to my notice in which failure 
was due solely to what might properly be called 
"scamped," superficial, or snapshot diagnoses. 

A diagnosis cannot be too thorough. Frequently 
the investigative procedures which the physician carries 
out may have led him to make an absolutely correct diag- 
nosis so far as it goes, but it may not be as complete 
as it might have been, and as a result, unnoticed condi- 
tions are allowed to flourish, the existence of which cur- 
tails very markedly the benefits which his well-directed 
therapeutic procedures might have otherwise accom- 
plished. 

A prominent physician recently said, and rightly: 



Sucess in Chronic Disease 37 

"Shortcomings in diagnosis frequently allow human be- 
ings to suffer for years who might, were diagnosis made 
clear, be healthy useful citizens all that time." He spoke 
of a habit to which some of the profession are unfortu- 
nately addicted, "of skipping over the real diagnosis 
altogether, and rushing pell-mell into the treatment, so- 
called." 

The diagnosis of chronic disease is not reached as 
rapidly as that of typical smallpox or diphtheria; nor 
does the patient expect it at once. I well remember a 
difficult case in which the diagnosis was not arrived at 
for three months — but it was finally right, and a condi- 
tion of many years' standing was first modified and then 
cured. 

In the majority of cases we must treat not merely 
a disease alone. It must be evident, for example, that 
a patient suffering from tuberculosis should not merely 
receive treatment with reference to the particular infec- 
tion with the tubercle bacilli alone. The inevitably low- 
ered vital resistance, and the associated infection with 
germs other than the tubercle bacillus, should be looked 
after just as thoroughly and systematically as the tuber- 
culin-hygienic treatment is carried out. The digestive 
apparatus should be watched as closely as the tempera- 
ture, and very great attention paid to the elimination 
of waste from the body, as evidenced in the urinary 
findings. Right here, it might be well to suggest that 
the old fad of "stuffing" a patient is hardly rational in 
the light of present-day knowledge, and if the physician 
takes the trouble to properly look after the elimination 



38 Essays on Laboratory Diagnosis 

of his patient and see just what the "dozen eggs a day" 
are doing to his patient's metabolism, he would easily 
recognize that this change is worthy of closer considera- 
tion, because it is based on good common sense. 

The estimation of the urinary acidity, the estimation 
of urea and ammonia, as well as the examination for 
indican and other abnormal substances in the urine, will 
all surprise the physician treating cases of the character 
under discussion, for by these means he will soon dis- 
cover that the kidneys are being unduly overburdened, 
that the intestines are filled with a reeking mass of putre- 
fying albumin, and that the patient is suffering from 
a toxemia probably equally bad, if not worse, than the 
toxemia due to the activities of the tubercle bacillus 
itself. 

It will be plain that to accomplish these ends the 
usual abbreviated methods of physical investigation will 
not suffice. Recourse should invariably be had to certain 
laboratory procedures varying to some extent with the 
history, physical findings, etc. In every case a complete 
urine examination should be made. If there is rea- 
son to suspect gastro-intestinal disturbance, do not be 
satisfied with answers to a few questions, or even with 
the most thorough physical examination. Procure and 
examine the stomach contents after a test-meal given in 
the proper way. Frequently a fecal examination (chem- 
ical and bacteriological) will throw so much light on a 
case, that the unpleasantness of the procedure will be 
altogether overshadowed by the definite knowledge ob- 
tained, and the results that this may make possible. The 



Success in Chronic Disease 39 

microscopic examination of pus, sputum or other secre- 
tions, and not uncommonly a blood examination or a few 
simple tests of the saliva will be of much valuable as- 
sistance in the work. In this connection it will not be 
out of place to remind the reader of the help that a 
Tuberculin reaction (either that of von Pirquet or Moro) 
may be. This comparatively new procedure is used alto- 
gether too little, and has not yet received the attention 
it deserves. 

The blood-pressure instrument or sphygmometer is 
not used as frequently as it might be. It is compara- 
tively rare to see an instrument outside of the physician's 
office in the larger cities or in up-to-date institutions. 
The blood-pressure is a point of tremendous value, and 
I am not overstating the truth when I say that it should 
be estimated as a routine in the investigation of every 
chronic case. The new Faught instrument is as simple 
and compact as one could wish, an ornament, and an 
essential to every progressive physician's office. 

Another factor which plays a very important part in 
the successful outcome of the treatment of chronic dis- 
ease is the co-operation of the patient. It must surely 
be evident that if the physician is attempting to correct 
certain disturbances and at the same time certain per- 
nicious habits or customs of the patient are adhered to 
in spite of advice to the contrary, the physician is very 
much handicapped in his treatment, and should not be 
held responsible for any failure that may possibly result. 

It might be well here also to refer to the need for 
regularity in the treatment. This is a very important 



40 Essays on Laboratory Diagnosis 

point. For example: For the relief of any given con- 
dition, office treatment may only be required every ten 
days or so; again, treatment may be necessary two or 
three times a week; and at times daily attention may be 
advisable in order to obtain the desired results. It 
must be plain that if one particular treatment brings a 
patient to a certain stage, and in a sense prepares him 
for the next, the omission of a treatment, if a matter of 
common occurrence, will materially decrease the value 
of the whole series. It is because of this that the opin- 
ion is quite prevalent that chronic disease, to be suc- 
cessfully handled, requires the hospital or sanitarium 
regimen, since the patient is under full control and can 
receive such treatment as may be deemed advisable 
without any break or inconvenience. This is true, but 
I believe, nevertheless, that any thinking individual, by 
dint of a few gentle reminders, would have sense enough 
to see to it that the treatment is as regular as possible, 
and at the same time that the advice of the physician is 
explicitly carried out. 

A point might well be made here regarding the in- 
structions given to patients. Many times dietetic and 
hygienic suggestions are made in the office, and because 
of these the patient starts out very well. He eschews 
certain articles of diet as suggested and regulates his 
living very carefully — for a time. In a few days he 
forgets one item, then another, until finally he is back to 
the same old slough in which he was wading before he 
came to the office for attention. To obviate this, I be- 
lieve it to be by far the best plan to give definite written 



Success in Chronic Disease 41 

instructions to the patient as to what he should eat and 
what he should not eat; to give him in black and white 
the most important general instructions regarding his 
method of living, and make your ideas so clear that 
there may be no mistake regarding them. Of course, a 
copy of these instructions will be kept on file with the 
case history, prescription copies, and other records. The 
instruction slip may well be shown to some member of 
the patient's family in order that their co-operation may 
also be obtained in helping the individual under treat- 
ment to faithfully "toe the mark." 

The original initial examination of the patient is not 
enough. Careful watch must be kept of the changes 
which may be due to the treatment or to other circum- 
stances. Personally, I consider it of prime advantage 
to be able to make frequent urinalyses, for in this way 
the variations in the metabolism are shown up and the 
changes resulting from the treatment are made clear. 
It is often an excellent plan to administer certain reme- 
dies, using the urinary findings as the guide to dosage. 
The results obtained are sometimes phenomenal, and 
no physician once accustomed to these methods will re- 
vert to the older (but admittedly less arduous) way. 
As far as repeated examinations are concerned, the same 
holds true of the gastric contents, feces, etc. Ofttimes 
the treatment is having a decidedly beneficial effect, 
although for a time no great modification of the patient's 
subjective symptoms is apparent. The progressive favor- 
able change in the laboratory reports, however, is always 
*a source of encouragement, not only to the physician, 



42 Essays on Laboratory Diagnosis 

but also, when properly explained, to the patient. 

There is another matter which seems quite difficult 
to instill into the minds of individuals suffering from 
chronic disease. I refer to the need for a more ex- 
tended and systematic oversight of themselves after they 
may have passed from the close attention or immediate 
care of their medical adviser. The human body is very 
like a machine, and if an engineer should mend some 
broken part, see that it worked properly, and then leave 
the whole machine to the tender mercies of chance with- 
out any regular supervision, he would very soon be in 
serious trouble. Instead, he feels the bearings, oils them 
carefully, tightens a loose nut here and there, and gen- 
erally scrutinizes the machine with a special care and 
watchfulness, in this way anticipating trouble before it 
comes, and preventing what might frequently cause a 
serious accident. This same thing is just as true of the 
human machine, and it becomes the duty of the physi- 
cian to exercise just as much care and intelligent over- 
sight as does the engineer. I firmly believe that a peri- 
odical and regular investigation of any individual who 
can be interested in this idea will lead to much more sat- 
isfactory work in the practice of medicine, and, at the 
same time, prevent, in their onset, a host of entirely 
needless chronic diseases. Such systematic care of an 
individual may often prove a means to very valuable 
ends, and if this article does nothing more than to im- 
press upon the reader the great necessity for periodic, 
clinical as well as physical examinations, it will be well 
worth the time and trouble taken to write it. 



Success in Chronic Disease 43 

In conclusion, I might summarize the following es- 
sential points : 

1. Obtain a thorough diagnosis, no matter how much 
it costs or how long it may take. 

2. Find out all that is the matter with the patient. 
Do not be satisfied with simply finding some evidence of 
disease and overlook the rest of the body and other asso- 
ciated difficulties. 

3. Be sure you are right, then go ahead, making use 
of the most rational methods that you know of, and push- 
ing all your treatment to effect. 

4. Always couple whatever therapeutic method you 
may be using with the most thorough elimination possi- 
ble under the circumstances. 

5. Obtain the confidence and complete co-operation 
of the family. 

6. Make frequent repeated examinations of the urine 
and, if needs be, of other specimens. This favors thor- 
ough work, and gives confidence to the patient. 

7. Teach your patient something at each office visit; 
send him away from your office with an Increased knowl- 
edge of some matter he was not previously aware of, 
and thus educate him in the prevention of disease. 

8. Make the patient realize that he is liable to get 
into trouble again, to consult you regularly, and thus 
prevent the recurrence of disease in its incipiency. 



IV. 

AN IMPORTANT ELEMENT OF SUCCESS IN 

THE TREATMENT OF CHRONIC 

DISEASES. 

Reprinted from 

THE MEDICAL STANDARD, 

Chicago, 

October, 1909. 



CHAPTER IV. 

AN IMPORTANT ELEMENT OF SUCCESS IN 
THE TREATMENT OF CHRONIC 
DISEASES. 

The treatment of the large class of diseases that goes 
under the name of "chronic" is probably the most diffi- 
cult part of the work of the general practitioner, and 
usually offers more opportunities for failure than any 
of the other branches in medicine. There are several 
important reasons for this: First, the difficulty in rec- 
ognizing absolutely the conditions with which one has 
to contend. Second, the defective education of the pub- 
lic, which at present has not reached that point which 
tells them to visit the doctor early, the majority usually 
waiting until they show evidence of serious trouble; 
and, third, the difficulty in keeping patients under close 
observation and carefully following the prescribed regi- 
men. For this reason many sanitariums have sprung 
up in all parts of the country, where individuals live, 
eat, receive various forms of treatment by trained as- 
sistants and are under the direct care of physicians all 
the time. 

However, not all those suffering from chronic dis- 
ease can or will, for many reasons which need not be 
mentioned here, visit such institutions, and consequently 
must depend upon the general practitioner for help. Un- 
fortunately, failures are only too frequent, and usually 
the reason for this is not far to seek. Perhaps a thor- 
ough examination of the patient is made by the physi- 



48 Essays on Laboratory Diagnosis 

cian, and perhaps not. Thus, I once met a man afflicted 
with a serious disturbance of the lung, who assured 
me that he had consulted a number of supposedly prom- 
inent physicians, but that I was the first one who had 
him take off his shirt to examine his chest. Then, 
again, there may be a most careful discussion of the case, 
coupled, possibly with a physical examination, after 
which the patient is sent about his business by the lazy 
doctor with the prescription for one of his stand-by rem- 
edies in his pocket. 

It is admitted that all physicians do not reduce their 
investigation of the cases coming to them to the degree 
hinted at above, nevertheless, it is a deplorable fact that 
the majority take far too little time in the investigation 
of the conditions present in their patients. Their minds 
seem to center around the subjective symptoms mani- 
fested by the patient, and on what facts he may have to 
bring for the physician's consideration. The findings 
which are only noted after questioning or at the expense 
of considerable time are in the majority of cases not 
brought out. 

Absolutely nothing adds so much to the success and 
professional reputation of a physician as thoroughgoing, 
conscientious diagnostic work. Too much time cannot 
be spent on t'he investigation of any given case. Ninety- 
five per cent of all the failures that I have noticed in 
my practice among those that have been treated by one 
or more other physicians have been wholly and solely 
due to scamped diagnoses. And all the hard feelings, 
depleted pocket-books and hurt reputations might have 



An Element of Success 49 

been avoided had sufficient time and trouble been taken 
to make a thorough investigation first thing, 

I will not take space here to discuss the ins and outs 
of physical diagnosis, but do wish to call particular at- 
tention to the necessity, importance and great value of 
the laboratory report as an efficient aid in solving the 
riddles which so frequently come to the physician for 
solution. 

No one scientific procedure will give so many and so 
varied therapeutic pointers as the careful and thorough 
examination of the urine. By an "examination" of the 
urine I do not mean the simple testing for albumin and 
sugar, tests which are only the confirmation of definite 
structural changes in the tissues already established, but 
rather the extended qualitative, quantitative and micro- 
scopic examination, which permits of the detection of 
early functional disturbances, particularly of metabolism, 
which give warning of the insidious onset of disease 
in sufficient time so that it may be warded off. 

I believe that I am not overstating the matter when 
I say that all cases of chronic disease, without exception, 
are either due to, or at least associated with, definite 
disturbances in the metabolic functions of the body. 
Just what these disturbances are, and the extent to which 
they have gone, remains for the laboratory man to dis- 
cover. Just how bad the trouble is will be evidenced 
by the laboratory report, which then becomes an efficient 
guidepost to definite, result-bringing medication. 

One of the most common diseases we meet is tuber- 
culosis. I will venture the statement that if the labora- 



50 Essays on Laboratory Diagnosis 

tory is thought of at all, in the diagnosis of pulmonary 
tuberculosis, it is for the examination of the sputum. 

Recent medical literature contains many references 
to the determination of the presence of the tubercle ba- 
cilli in the blood of those infected with this disease, and 
it has been declared by some that the bacilli in question 
are found in practically every case, whether in its incip^ 
iency or far advanced. This must surely be a mistake, 
although it must be granted that in some cases the blood 
culture made in the proper way gives definite evidence 
of the presence of the germ. 

However, there is another important laboratory ex- 
amination — the urine analysis. This, it is true, gives no 
special informcftion as to the presence or absence of the 
specific germ of tuberculosis, but does give information 
of tremendous value, since it points out the need for the 
readjustment of the functions of the body. If the tu- 
bercle bacilli are attempting to gain an entrance into the 
body, every untoward influence which might either favor 
the activities of the invader or hinder the activities of 
the body in general, but more especially the white blood- 
cells, will be made known. 

From such an examination we learn whether the ex- 
creting functions of the kidneys are normal or not; 
whether the condition of the intestines is favorable to 
the highest degree of vital resistance; whether the liver 
is performing its full duty ; whether there is an acid in- 
toxication of the system which would diminish the oxy- 
gen-carrying power of the blood, thus lowering its germ- 
icidal properties; and whether the oxidizing power of 



An Element of Sncress 51 

the cells, or in other words, metabolism, is up to the nor- 
mal or not. 

What is the relation of diminished urea excretion 
to the possibility of infection by the tubercle bacillus? 
Perhaps not direct or even close, but undoubtedly a dim- 
inution of this normal waste product may have an influ- 
ence which will be favorable to the entry of the germ 
into the body. 

Now, what effect, if any, do the conditions associated 
with an excessive degree of urinary acidity have upon 
this particular matter? 

I have been told by some that there is absolutely no 
relation at all between these two factors, and that I had 
wheels in my head. This may possibly be true, but still 
the facts evidenced by many laboratory examinations 
seem to prove the contrary. As a matter of fact, the 
examination of the urinary excretion of a large num- 
ber of patients suffering from tuberculosis in all forms 
showed an invariable increase in the urinary acidity, with 
the one general exception that in those in which there 
was retention of the urine with a resulting alkaline fer- 
mentation and neutralization of the degree of acidity, 
whether normal or excessive. This is no accident or 
mere coincidence; it is a finding which will be noted in 
practically every case, and fortunately is one which 
brings with it a knowledge of a very simple, satisfac- 
tory and successful therapeutic measure. 

While the disturbed metabolic conditions causing sys- 
temic acidemia may not be thoroughly changed, yet the 
increase in the diminished normal alkalinity of the blood 



52 Essays on Laboratory Diagnosis 

can be immediately accomplished, with a resulting change 
for the better in its oxygen-carrying capacity. 

It must not be supposed that because I have made 
this statement, that the use of sodium bicarbonate or 
alkalies in general is advocated as a specific for tubercu- 
losis. Far from it. But I thoroughly believe that the 
use of this drug, or others giving similar results, will do 
much to favor the natural resisting power against dis- 
ease in general and tubercle bacilli in particular; and 
thus aid the individual in the hard battle which he has 
to fight. 

What has been said above is not only true of tuber- 
culosis; that is not the only "chronic" disease. There 
are many diseases, some of which, perhaps, are not spo- 
ken of by any one definite name, yet which most as- 
suredly can be treated. 

Take, for instance, the tendency or susceptibility to 
"colds." Some individuals have a cold almost every 
month; others take the annual "cold" as a matter of 
course, and when the time comes for its appearance, 
quinine, aspirin, acetanilid and other frequently-used 
remedies are the only things thought of. No attention 
whatever is given to the cause of the cold, for this is 
thought to be too simple a matter to require investiga- 
tion. 

Supposing an examination of the urine were to be 
made in the investigation of an individual otherwise 
seemingly well, but who has just caught a severe cold. 
In ninety cases out of a hundred there will be found 
an excessive degree of urinary acidity. Probably indi- 



An Element of Success 53 

can will be present to a greater or less extent, with both 
the amount of urine and of total solids materially dimin- 
ished. 

Are these findings mere coincidences? By no means. 
Indeed, are they not rather evidence of definite disturb- 
ances which may and should be rationally and success- 
fully treated. 

If this is so, is the treatment of a cold complete when 
soda is administered in the proper dose ? Not at all ; but 
if there is an excessive degree of acidity, alkalies un- 
doubtedly are called for; if the physician in addition 
desires to use an antipyretic, or an analgesic, or a 
soporific, or any other remedy, he may, of course, do 
so, certainly. 

The foundation of all chronic disturbances, from 
rheumatism to neurasthenia, and from tuberculosis to 
a common cold, is due to a change in the normal metab- 
olic functions of the body. Just the exact spot where 
the difficulty is concentrated, or just when or how the 
trouble began may never be ascertained. Still, it is a 
fact that the conditions present in the intestines will be 
found to cause a great deal more trouble than is at pres- 
ent attributed to them. Indican in itself may be non- 
toxic, but its presence in the blood, and consequently in 
the urine, is an evidence of the presence of other tox- 
ins generated at the same time and in the same locality, 
and which undoubtedly are the cause of numerous ail- 
ments. These pathologic substances, usually acid in re- 
action, neutralize the normal alkalies in the blood-plasma 
and generally disturb the whole series of the oxidizing 



54 Essays on Laboratory Diagnosis 

functions of the body-cells in general. Just what these 
substances are is not yet known, but clinical results 
show that they may be rendered practically innocuous 
by neutralization with alkalies. 

To sum up, the investigation of all chronic disease 
is not complete unless a thorough urinalysis is made, 
and chief among the points learned from this work is 
the degree of acidity, since that throws a direct light 
on the metabolic and eliminative functions of the body. 



V. 

MYSTICISM AND MEDICINE. 

Editorial in 

THE MEDICAL STANDARD, 
Chicago, 

March, 1910. 



CHAPTER V. 
MYSTICISM AND MEDICINE. 

There was a time, and not so long ago either, when 
the doctor depended in no small degree upon the mys- 
tical element for his aid; the more uncanny his proced- 
ures, the greater his influence over those who came to 
him for medical service. Only a comparatively few 
years ago physicians made mystery a prominent factor 
in their work. Unfortunately, even today there is still 
a tendency in this direction and there are many physi- 
cians who consider their knowledge uncommunicable, 
and under no consideration will enter into explanations 
of any kind to their patients. 

In civilized countries we are fortunately gradually 
getting farther removed from the methods of witch 
doctors and the influence of fetishes ; although, strange 
to say, some of the ideas still prevalent regarding dis- 
ease and its treatment are as crude and absurd as the 
strange orgies of past years about which we sometimes 
read and throw up our hands in horror. 

Mysticism has no place in medicine. Nowadays pro- 
gressive physicians make it a point to take their patients 
into their confidence, explaining the circumstances and 
conditions as clearly as possible, and often giving a 
definite reason for their actions and requests. This in- 
spires confidence in their work, and the patients, with 
rare exceptions, follow with evident interest the prog- 



58 Essays on Laboratory Diagnosis 

ress made in their treatment from day to day. 

It is unfortunate that many physicians still have the 
erroneous notion that their knowledge is of such a kind 
that it cannot well be imparted to the layman. This 
may to a certain extent be true; we do not pretend that 
abstruse medical problems, which may be hazy even to 
the student of years, can be explained to the full satis- 
faction of those unlearned in medical science but we do 
contend that a rough, general idea of the processes of 
the body that may be involved in the particular case in 
question, and of the raison d'etre of the treatment, are 
desirable in the proper handling of the majority of cases. 
Not that the actual remedy or combination of remedies 
and their dose need be disclosed, or that a morbid inter- 
est be aroused in the patient — far from it. There is 
such a thing as going too far and there is no such idea 
in our minds; but we feel, nevertheless, that there are 
good grounds to stimulate a greater interest in the edu- 
cating factor of the general practitioner's work. 

The educating physician — the man who is not afraid 
to take a few minutes of his time to give a reason for 
his action — is a constant source of valuable and helpful 
knowledge to his patients, and far from confusing their 
minds, by giving a reasonable account of his work, he 
makes for unwavering confidence on the part of the pa- 
tient and an intelligent interest in carrying out to the 
letter the needful personal hygienic reforms which are 
essential in preventing the recurrence of the disease — 
conditions which may have been the means of bringing 
doctor and patient together. 



Mysticism mid Medicine 59 

The disadvantages of eliminating mysticism from 
medicine are not confined to the patient alone. The 
confidence thus inspired brings with it actual therapeutic 
results that are sometimes phenomenal, and the reflex 
benefit to the doctor who thus makes it his routine to 
take his patients into his confidence, is evidenced in the 
increasing professional reputation that invariably follows 
work of this kind. With intelligent confidence comes 
intelligent cooperation — an absolute necessity in the hard 
struggle so often needed in the treatment of chronic con- 
ditions. 

We are continually admonished in moral philosophy to 
"be open" — "be honest" — "be above-board," and we firm- 
ly believe that a little more straightforwardness and a 
little more frankness in medicine would have its advan- 
tages. The wise physician of to-day is the one who re- 
gards himself as the educator of such individuals as 
may come in contact with him. In explaining various 
matters that may come up from time to time, he safe- 
guards their bodily interests just as the lawyer safe- 
guards the business interests of his client. His great 
effort is not merely to remove the symptoms but to pro- 
tect the patient from his own errors and their unavoid- 
able results — by education. 

There is still a large number of medical men who 
seem to cater solely to the subjective ills of their con- 
sultants. A man comes into the office with constipa- 
tion — he receives a few pills, Hinkle's, we'll say. No ef- 
fort is made to determine the kind of constipation, nor 
to find out what far-reaching effects may already be 



60 Essays on Laboratory Diagnosis 

present. The patient is not looking for this kind of 
service. He came expecting a pill and got it. Another 
comes complaining of indigestion, flatulence, eructations, 
etc. — he, too, gets a supply of tablets and, all too fre- 
quently, no investigation as to the seat and extent of 
the trouble is even thought of. He was not expecting 
more and is satisfied with temporary, symptomatic help. 

Just as the modern progressive merchant refuses to 
handle shoddy or to supply it even to those who may 
demand it, since it would be inimical to the trade to 
which he was catering, so the progressive physician re- 
fuses to do slip-shod work masked with a specious air 
of mysticism, simply because his patients do not know 
enough to ask for more than the pill or tablet. There 
are demands which he should not supply — at least until 
he is in possession of diagnostic facts upon which to 
base a sensible rational treatment. 

There is much room for progress in the education of 
the public along these lines. They should be taught to 
appreciate the need for the careful and thorough exami- 
nation. They should learn the "why" and the need of 
the clinical laboratory. They should be shown the rea- 
sonableness of the special care exerted in the treatment 
of the ills from which they may be suffering. As it is 
now. the majority will not permit real, thoughtful service 
without a previous explanation of its need and advan- 
tages. And simply because this requires work, hard 
work, too many physicians still clothe themselves with 
the mystical in medicine, and depend upon chance and 
a few pills, rather than upon real, dependable facts ob- 



Mysticism and Medicine 61 

tained by careful clinical and laboratory investigation. 
The physician who acts upon sound principle and re 
fuses to dispense shoddy in his practice, at least when 
it is desired, is still a vara avis — may his tribe increase? 



VI. 

THE ADVANTAGES OF THE URINE 
EXAMINATION. 

Reprinted from 

THE MILWAUKEE MEDICAL JOURNAL, 
Milwaukee, 

December, 1909. 



CHAPTER VI. 

THE ADVANTAGES OF URINE EXAM- 
INATION. 

By dint of persistent work on the part of laboratory 
investigators, the examination of the urine has at last 
become generally recognized as an essential part of any 
thorough medical examination by both medical profes- 
sion and laity. All first-class insurance companies now 
require some sort of a urine examination as a part of 
the usual investigation of the prospective policy holder. 

The advantages of this procedure may indeed be 
summed up in a single sentence: "No one diagnostic 
procedure gives us so many and so varied therapeutic 
pointers as does a thorough urinary analysis/' 

In the title of this paper, the word "possibilities" 
might well have been substituted for the word "advan- 
tages." The possibilities of the urine examination are 
by no means as circumscribed as is usually supposed. 
Even in these days of efficiency in medicine, the ordinary 
"examination" of the average physician does not imply 
very much more than the simple tests for albumin and 
sugar; and opportunities for making a valuable investi- 
gation of the condition of any individual are surely 
missed unless, in addition to the old-time simple quali- 
tative examination, a thoroughgoing physical, quantita- 
tive as well as qualitative chemical and microscopic ex- 
amination is made. 

Contrary to an impression that is still quite prevalent, 



66 Essays on Laboratory Diagnosis 

the urine analysis does not give information as to the 
condition of the kidneys alone. True, the presence of 
certain definite urinary findings is usually considered 
good evidence of the presence of equally definite disease 
conditions in the kidney structure itself, but this is only 
a very small part of the information that can be gained. 

If this were the only purpose served by the urine 
analysis, its office would be an exceedingly meager one, 
for, in the first place, its value would be limited to cor- 
roboration, simply confirming what has already been ob- 
served from physical examination, and, in the second 
place, it would only serve to disclose what is known as 
terminal disease, L e., practically hopeless changes in the 
tissues themselves. Thus the outcome of the common 
search for albumin and casts in the urine is to demon- 
strate those diseased conditions of the kidneys which 
are classed (in honor of a famous physician) under the 
name of Bright's disease. But by the time these condi- 
tions are thus shown to be present, the kidney tissues 
are degenerated to such an extent that the urinary find- 
ings are of little or no therapeutic value. 

But, fortunately, since the days of Dr. Bright, the 
work of hundreds of progressive investigators, both at 
the bedside and in the laboratory, has proved beyond a 
shadow of a doubt that the earliest beginnings of kidney 
disturbance are disclosed in a complete urine examina- 
tion long before the serious and destructive organic 
processes have begun. In other words, the functional 
disturbance is manifested before organic change is pres- 
ent. And while the course of an established nephritis 



Advantages of Urine Examinations 67 

or Bright's disease is not specially benefited by the 
urine analysis, if the analysis is made early enough, 
its insidious onset may be noted and appreciated 
in time to render valuable preventive treatment. 
Usually, however, such an examination is not made un- 
less some special reason arises for making a complete 
and thorough investigation, and it is only in the excep- 
tional cases that the opportunity is thus gained to save 
the unsuspecting individual from the trouble to which 
he is unwittingly, but nevertheless most surely, becoming 
a victim. 

To be of the greatest possible value to the individual 
the urine examination should be sufficiently complete 
and exhaustive not only to detect the actual evidences 
of disease, but to lay bare those seemingly harmless con- 
ditions which, when consummated, may become serious 
and all too often hopeless. In addition to this, the fre- 
quency of the tests is a matter of importance, for, as pre- 
viously stated, serious trouble is very frequently averted 
because of the accidental findings of some specific point 
of importance. To change this preventive measure from 
a, mere accident into a premeditated, systematic search, 
it is suggested that a regular and thorough examination 
of the urine be made, from time to time, for such indi- 
viduals as may appreciate the advantages that such a 
service would be to them. This affords a very good in- 
sight into the ups and downs of their metabolism, or the 
workings of the intricate parts of the body as a whole. 

The urinary analysis made periodically, and that, too, 
without the necessity of the presence of evident ill- 



68 Essays on Laboratory Diagnosis 

health as a reminder of the need of it, enables the man 
who is "burning the candle at both ends" or living the 
abnormal sedentary life so very common in large cities, 
to forestall the conditions that his high-tension life is 
inevitably causing, before extended damage has been 
done and chronic disease has seized upon him in the 
prime of his business or professional life. 

Probably the most common abnormal findings in the 
urine of the average individual are those which are due 
to, or associated with, disordered functions of the aliment- 
ary tract. From the mouth to the rectum, disturbances 
which are seemingly trivial mirror their presence un- 
erringly in the secretion of the kidneys. As an illustra- 
tion of this, extended experiment has shown a definite 
relation between pyorrhea alveolaris, a serious and un- 
fortunately common mouth disease, and the presence of 
certain abnormal substances in the urine. Again, an 
eminent French authority has expressed himself as be- 
lieving that more information of value can be obtained 
regarding stomach disease by the examination of the 
urine than by one of the stomach contents themselves, 
although personally I believe that both examinations in 
conjunction would offer still more satisfactory service. 
The diseases of the liver and gall bladder often manifest 
themselves in their early stages by abnormal findings 
in the urine, in this way calling attention to the disor- 
dered condition before it has manifested itself in the 
usual outward ways. 

The intestinal canal — that "hot-bed of iniquity" in the 
human body — shows more deviations from the normal 



Advantages of Urine Examinations 69 

than any other part of the food-canal. Certain poisonous 
substances manufactured from the putrefying intestinal 
contents are taken up into the blood, causing innumerable 
aches and pains, malaise and languor, nervousness and 
irritability, as well as a host of other very common and 
equally unpleasant conditions. In the wonderful pro- 
tective economy of the body it becomes the duty of every 
part to assist in ridding the blood of any excess of 
poisonous materials that it may be carrying. The kid- 
neys have to do a large part of this work, and the pres- 
ence (and for that matter, the extent of the presence) 
of these substances in the urine is a suj;e guide to the 
seat and extent of the trouble, and incidentally a danger 
signal of extreme value. By following its guidance, a 
halt may be called upon the improper and extended use 
of the kidneys for carrying off waste products which 
normally should pass out through the bowels. It must 
be evident that should such conditions be allowed to 
continue unchecked, the overburdening of the kidneys 
with more than their proper share of the work must 
eventually result in a crippling of their functional ca- 
pacity. 

As an index of the nutrition and metabolism of the 
body the urine stands pre-eminent. If an individual is 
not receiving sufficient nourishment, this fact will 
quickly be shown in the urine examination. If the oxi- 
dizing power of the millions of body cells is deficient or 
increased, that, too, will be manifested very quickly in 
the relation between the different substances passed out 
in solution in the urine. By very extended experiments 



70 Essays on Laboratory Diagnosis 

the varioub urinary salts, organic and inorganic, have 
been shown to be very serviceable guides to the condition 
of the different parts of the body. For example, the 
phosphatic index and its fluctuations has been shown to 
have a definite bearing upon the nervous system and its 
nutrition, and in this way serves to point out the be- 
ginning of trouble which might, if allowed to proceed 
the usual course unchecked, soon go from bad to worse. 

One might go on ad libitum and enumerate the 
various urinary findings and their several importance, 
but this is not the function of this paper. The main idea 
of the writer is simply to call attention to the fact that 
a careful, regular and methodical investigation of the 
various substances normally eliminated in the urine and 
their relation to one another, together with a series of 
tests to prove or disprove the presence of any abnormal 
substances which might be present, will undoubtedly 
serve to call attention to the earliest beginnings of 
chronic disease, and in this way prove one of the most 
important prophylactic measures that it is possible for 
an individual to take, no matter whether he may be in 
seeeming good health or a semi-invalid. 

Such a service, if made systematically, may in time 
be classed with the many excellent measures adopted and 
fostered by the state and municipal governments, which 
in the present century are beginning to usher in the era 
of preventive medicine. 



VII. 
PROPHYLACTIC LABORATORY WORK. 

Editorial in 

THE MEDICAL STANDARD, 
Chicago, 

June, 19 w. 



CHAPTER VII. 
PROPHYLACTIC LABORATORY WORK. 

The laboratory has been utilized to the full for 
purely diagnostic purposes; almost too much, one is 
tempted to think, when one considers how diagnosis has 
come to be based upon isolated objective conditions which 
too often represent the last structural changes wrought 
by disease, rather than upon the functional derangements 
in which the disease usually has its beginnings. The 
spirit of the times demands prophylaxis in diagnosis as 
well as in treatment, and the physician who would keep 
pace with that spirit must learn to use his laboratory, 
not simply for the confirmation of already established 
morphological changes in the tissues, as in the demon- 
stration of glycosuria, albuminuria, and the like, but for 
the detection of early functional disturbances, especially 
of metabolism, which herald the onset of disease, so 
that it may be successfully headed off. 

Happily, laboratory men and methods are exhibiting 
a commendable tendency in this direction. The text 
books, it is true, are still wofully behind the times, but 
live men in the laboratory field are pointing out, in timely 
articles and monographs, how the test tube and the micro- 
scope may be given a broader and more helpful range 
than the mere demonstration of structural breakdowns. 
The value of urinalysis, in particular, has only just be- 
gun to be appreciated in its quick, sensitive response to 



74 Essays on Laboratory Diagnosis 

the slightest metabolic derangements. 

Consider, as an example, the significance of the acid- 
ity of the urine. To this day the standard text books 
on clinical diagnosis make absolutely no mention of this 
important diagnostic feature, the extent of their ref- 
erence to urinary acidity being usually comprehended 
in the bald statement that "the urine is normally acid." 
Yet it has been proved beyond reasonable doubt that 
the varying degrees of acidity are pregnant with hitherto 
unsuspected significance concerning the conditions of 
metabolism, and furnish invaluable data for the interpre- 
tation and management of clinical cases. 

We refer to this simply as an illustration of the truth 
with which we started out, namely, that the uses of the 
laboratory are but in their infancy — indeed, the real value 
of this method of diagnosis has not yet been appreciated 
or utilized. Of all the means at our command for 
prophylactic purposes, none offers a more promising 
field than this very one of the laboratory. 



VIII. 
ROUTINE URINE EXAMINATIONS. 

Reprinted from 

THE NEW YORK MEDICAL JOURNAL, 
New York, 

February 2jih, 1909. 

Copyright, 1909, by A. R. Elliott Pub. Co. 
Reprinted by permission. 



CHAPTER VIII. 
ROUTINE URINE EXAMINATIONS. 

That the examination of the urine is a procedure of 
considerable diagnostic importance cannot be gainsaid. 
The physician who makes it a regular practice to per- 
form a complete urinary examination will have a most 
decided advantage over his professional brother who is 
readily satisfied with just the few perfunctory tests per- 
formed with a test tube, some nitric acid, and Fehling's 
solution. 

The majority of the medical profession — the average 
general practicians — are rapidly reaching a point in their 
experience where the most careful and complete diag- 
noses are absolutely essential to their professional suc- 
cess, and for this reason I believe that the routine exam- 
ination of the urine will soon be carried out by every 
progressive practician, no matter where he may be lo- 
cated, whether in the busy city, with its facilities and 
competition, or at the country crossroads where the facil- 
ities are meagre and there is little competition, or none 
at all. 

In this particular department of medicine — scientific 
laboratory work — the time element involved undoubtedly 
has played a very considerable part in preventing the 
average man from carrying out these investigations in 
his own laboratory, but with the progress in technique 
and the simplification of the methods in vogue, this work 



78 Essays on Laboratory Diagnosis 

is rapidly becoming a much less burdensome matter to 
the busy man, and the time now required for the com 
plete qualitative and quantitative urinary examination 
has been reduced to a minimum. 

Ctf course, the examination for sugar and albumin 
will always hold a high rank, as the presence of either 
of these substances in the urine points out definite dis- 
turbances, but considerable variation is manifested by 
different laboratory investigators as to the relative im- 
portance of the various quantitative estimations of the 
normal urinary ingredients; at least, if their published 
arguments are to be accepted. Thus, some men think 
that the estimation of the urea is by far the most impor- 
tant individual test, while others place much confidence 
in the estimation of uric acid. Other writers, again, 
hold still different notions. 

As for myself, I consider the accurate estimation of 
the degreee of urinary acidity of paramount importance, 
for, so far as my experience goes, a large proportion of 
disease conditions, both organic and functional, are al- 
ways associated with disturbance of metabolic processes 
which so modify the chemical qualities of the blood that, 
because of these changes, the urinary acidity is markedly 
increased. 

Unfortunately this test is rarely carried out by the 
majority of physicians. A perfunctory test with the prac- 
tically useless litmus paper is about as far as they go, 
and it must be admitted that the value of this is almost 
nil. 

And, yet, the quantitative estimation of the urinary 



Routine Urine Examinations 79 

acidity is a comparatively simple matter and gives infor- 
mation that is as definite as it is valuable. The variations 
offer a very good guide as to the metabolic processes in 
the individual. 

The examination of a large number of specimens 
leads me to believe that high urinary acidity is associ- 
ated in a majority of cases with low urea output and 
with other metabolic disturbances, possibly of the uric 
acid type, but not necessarily so. 

Again, I have found that high urinary acidity and 
indicanuria quite frequently are associated, and I begin 
to believe that this high acidity is due to the same condi- 
tions causing the presence of indican and the conjugate 
sulphates. At all events, in patients showing excessively 
acid urine, bacteriological examination of the faeces in 
a majority of cases demonstrates a severe infection 
within the intestines, together with putrefaction of their 
contents and the inevitably resulting autotoxaemia. 

Considerable work has been done during the last 
year or two in the investigation of autointoxication as to 
its cause and cure, and in this connection Professor Eu- 
gene S. Talbot, of Chicago, deserves special mention. 
Dr. Talbot has definitely proved the relation between 
autointoxication with high urinary acidity and certain 
mouth diseases — such as gingivitis with pyorrhoea are- 
olaris, etc., and his method of treating these conditions, 
by reducing the acidity of the blood, if I may so call it, 
using the urinary acidity as the index, is to my mind a 
decided step along the line of progressive medicine. It 
will be found that those remedies that reduce urinary 



80 Essays on Laboratory Diagnosis 

acidity to normal distinctly modify many aches, pains r 
and inconveniences associated with a high degree of 
acidity of the body fluids, or, more correctly, a diminu- 
tion of their normal alkalinity. 

Fortunately the quantitative examination of the urine 
as to the amount of acid present has been made an ex- 
tremely simple matter, requiring as it does only an acid* 
imeter and a medicine dropper. With these at hand and 
a very little experience, just as accurate work may be 
done by any careful person as with the burette in the 
hands of an expert. 

I have said nothing here of the all important micro- 
scopical examination, which should, of course, be made 
in every case. 



IX. 

A NEW INSTRUMENT FOR THE ESTIMATION 
OF THE URINARY ACIDITY. 

Reprinted from 

THE NEW YORK MEDICAL JOURNAL, 
New York, 

January 2nd, 1909. 

Copyright, 1909, by A. R. Elliott Pub. Co. 
Reprinted by permission. 



CHAPTER IX. 

A NEW INSTRUMENT FOR THE ESTIMATION 
OF THE URINARY ACIDITY. 

In an attempt to simplify the technique of the various 
laboratory estimations, which should be much more fre- 
quently made by every general practician, I have for 
some time been working with a very simple little in- 
strument which I found useful in the estimation of the 
urinary acidity. 

It is not intended to supplant the very necessary grad- 
uated buret employed by workers in the larger clinical 
laboratories, but to provide the wherewithal for the busy 
man to perform this important test in daily routine. The 
idea was gained from a very handy little tube invented 
by Gunzberg for the estimation of the acidity of the gas- 
tric juice. 

The acidimeter which I have designed consists of a 
glass tube so graduated that 10 c.c. is the first measuring 
point. From this upward the tube is graduated in fifths 
of a degree to 100°, each degree representing the 
amount of decinormal sodium hydroxide solution re- 
quired to neutralize 100 c.c. of urine. 

The method of using the acidimeter is as follows: 
The tube is filled with the specimen of urine to be tested, 
until the lower edge of the meniscus is just on the 10 c.c. 
mark. Two drops of phenolphthalein indicator solution 
are added, and then with an ordinary medicine dropper 
decinormal sodium hydroxide solution is slowly added, 



84 



Essays on Laboratory Diagnosis 



J1O0V 

80'-f- 

70°-f- 
W-% 
50°-f 
4tf-J 
30^ 

lO'-f 



inverting the tube after each addition, 
until the color of the fluid has been 
changed from yellow to a light rose 
pink. The acidity in degrees is now 
read off on the tube at the level of the 
fluid. The normal urinary acidity of 
a mixed twenty-four-hour specimen 
should be between 30 and 40 degrees. 

If the urine is alkaline in reaction and 
it is desired to estimate the degree of 
alkalinity, decinormal hydrochloric or 
oxalic acid solution must be used in 
place of the sodium hydroxide, the pink 
color present being just discharged by 
the acid. 

The advantages of this instrument 
are: 

1. Facility of handling; it can be 
carried in the pocket or bag and is not 
easily broken as is the buret. No stand 
is required. 

2. Accuracy of results, the gradua- 
tions being just the same as in the 
standard delivery buret. 

3. Price; the first cost is consider- 
ably less than that of a buret, and, as 
the acidimeter is far less liable to break- 
age, the eventual cost is very much less. 

4. Simplicity; the general practi- 
tioner, his office attendant or his wife 
may be quickly taught its rapid and ac- 



A New Instrument 85 

curate use. 

I believe that this instrument will simplify the pres- 
ent laboratory facilities of the medical man, thus in- 
creasing his diagnostic capabilities and his professional 
success. 



X. 

A STUDY OF THE URINARY ACIDITY AND 
ITS RELATIONS. 

Reprinted from 

THE MEDICAL RECORD, 
New York, 

June 5th, 1909. 

Copyright. 1909, by Wm. Wood & Co. 
Reprinted by permission. 



CHAPTER X. 

A STUDY OF THE URINARY ACIDITY AND 
ITS RELATIONS. 

The estimation of the urinary acidity has in the 
past been considered a more or less useless procedure, 
the simple test with litmus paper sufficing for all pur- 
poses. The study of this subject does not seem to 
have received nearly the attention that it deserves, and 
it is to be hoped that this paper will serve to empha- 
size the fact that the quantitative examination of the 
urine for acidity is a most important procedure and 
a part of the urine examination which should always 
be carried out. 

The mixed 24-hour specimen of urine is normally 
acid in reaction, this condition being principally due to 
certain acid salts, in particular diacid sodium phos- 
phate, NaH 2 P0 4 . The acidity is probably due, in a 
measure, to other acid salts which are also present, 
although in considerably smaller amounts. The ex- 
periments of Voit and others have conclusively proven 
that uric acid has nothing to do with urinary acidity. 

The index of urinary acidity undoubtedly varies 
in direct ratio with the metabolic changes going on 
in the body. The manufacture, as waste products, in 
the body cells of acid substances — of which sulphuric 
acid is probably the most important — must have a de- 
cided influence upon this factor. In addition to this, 
certain products of intestinal putrefaction when ab- 



90 Essays on Laboratory Diagnosis 

sorbed into the blood are eliminated in the urine and 
thus serve, as will be shown later, to increase its de- 
gree of acidity. 

Several factors cause the normal urinary acidity to 
vary considerably, such as an exclusive meat diet; ex- 
cessive muscular exercise; highly concentrated urine, 
due, perhaps, to febrile conditions, after free perspira- 
tion, or diminished water drinking. Then, too, the 
internal administration of acids, such as benzoic, phos- 
phoric or boric acid, and the presence of abnormal 
fatty acids resulting from pathologic conditions also 
play their part. 

Undoubtedly the degree of acidity of individual 
voidings of urine is quite irregular, and in order that 
the physician in his diagnostic work may gain an ac- 
curate idea of the elimination and metabolism of his 
patients, it is distinctly necessary to make an examina- 
tion of a part of a mixed 24-hour specimen of urine. 
This point cannot be too strongly emphasized. The 
urinary examination is usually not made nearly as fre- 
quently as it should be, and, unfortunately, when the 
physician realizes the necessity and importance of this 
procedure, he rarely bothers to have his patient make 
a complete 24-hour collection and take a specimen 
from it. 

One of the most common factors which has to do 
with the degree of urinary acidity is the concentration 
of the urine. That is, if the amount of urine is large, 
it is normally faintly acid, while, on the other hand, if 
the amount is below the average, the acidity should 



A Study of the Urinary Acidity 91 

be relatively higher. While this is usually the case, it 
must not always be depended upon, because it is a very 
frequent occurrence to find the urine of patients pass- 
ing considerably above the normal amount, even as 
high as three or four thousand cubic centimeters per 
diem, to evidence a considerable increase in the degree 
of acidity. In fact, an examination of a series of speci- 
mens of urine from diabetics and patients suffering 
from those forms of Bright's disease which are asso- 
ciated with the passage of large quantities of urine 
leads me to believe that this depraved condition of 
metabolism is constantly associated with such condi- 
tions as are evidenced by an excess of acidity due to 
the increased amount of acid substances eliminated by 
the body-cells. 

Dr. A. L. Benedict of Buffalo, N. Y., 1 mentions a 
factor which 1 think should be much more frequently 
used and given more publicity. I refer to the term 
"acid unit." An acid unit practically is determined by 
the relation of the acidity of a whole 24-hour specimen 
to the amount, thus: 1 c.c. of urine with an acidity of 
1° or 1 c.c. of urine exactly neutralized by 1 c.c. of 
decinormal sodium hydrate solution is equivalent to 100 
acid units. Dr. Benedict believes that the average urine 
is from one-fourth to one-half the equivalent of the 
decinormal strength, and that the normal acid elimina- 
tion in 24 hours should be about 40,000 acid units. 
This, I believe, is a very good average figure. It 
means that with one liter of urine the average acidity 
would be 40°, each degree representing the amount 



92 Essays on Laboratory Diagnosis 

of decinormal sodium hydrate solution required to neu- 
tralize 100 c.c. of urine. On the other hand, 1,300 
c.c. of urine with an acidity of 30° gives us practically 
the same number of acid units. The same is true of 
800 c.c. with an acidity of 50°. It can readily be ap- 
preciated, however, that this last figure cannot be nor- 
mal, as the total amount of fluid passed is too low, and 
consequently the acid-index too high. 

As has been said before, the accurate estimation of 
the urinary acidity is a matter of vital importance, and 
by making much more frequent use of it the physician 
will gain many valuable pointers which will enable him 
to treat his patients more successfully. 

It is unfortunate that so little attention is given to 
the value of this examinaion. There are many state- 
ments similar to the following, taken from recent books 
on the subject: "For the practitioner the mere deter- 
mination of the presence of an excess of acid or alkali 
by litmus paper is sufficient." 2 "For clinical purposes 
the litmus test is sufficient. In view of the many vari- 
able factors that determine the reaction of the urine — 
it is usually an altogether futile task to determine the 
urinary acidity by titration." 3 This is a decided fallacy. 
The examination of a large number of specimens of 
urine associated in every case with the clinical findings 
present in the individual passing these specimens shows 
conclusively that many unpleasant symptoms and even 
dangerous conditions are associated with, if not actually 
caused by, high urinary acidity and those disturbed 
metabolic conditions causing it. It is well known that 



A Study of the Urinary Acidity 93 

the urine is usually intensely acid in rheumatic condi- 
tions as well as in acute fevers, due in all probability 
to the increased manufacture of acids in the body tissues 
(a hyperoxidation of the body-cells) and, of course, 
the usual decreased amount of fluid secreted by the 
kidneys. That increased urinary acidity is distinctly 
abnormal seems to me to be proven by the findings 
which are given below. 

In a series of over 250 analyses the average urinary 
acidity was 60°, the lowest being 10° and the highest 
274°. (These specimens were examined in routine 
laboratory work.) Many of these individuals were 
passing urine with an acidity from 300 to 500 per cent, 
of the normal and with an acid-unit-index of from 
100,000 to 200,000 per day (the minimum in this series 
being 8,030 and the maximum 358,050), very much 
above the normal amount. 

The other findings show that in 35 per cent, of these 
cases casts and traces of albumin were found; and in 
83 per cent, of these cases indican was present to a 
greater or less extent, usually in large amounts. 

Eighteen of this series evidenced glycosuria with 
a sugar content varying from 0.3 to 13 per cent. In 
these cases the average acidity was 77°, with an aver- 
age acid-unit elimination of 132,130 — an increase of 330 
per cent., and in only one of these was there a positive 
test for acetone or diacetic acid. 

From these findings it would seem to me (1) that 
there is a distinct association between highly acid urine 
and autointoxication due to putrefaction of the intes- 



94 Essays on Laboratory Diagnosis 

tinal contents shown by the relation between indicanu- 
ria and high acidity; (2) that in diabetes an excess of 
acid (not necessarily diacetic or oxybutyric) is the rule, 
and in addition (3) that this condition of high acidity 
is very frequently associated with albumin and casts 
in the urine. 

It must be evident that an excessively acid urine 
must be more or less irritating to the kidney cells and 
tubules secreting it, and it is not unreasonable to sup- 
pose that such urine is a distinct factor in the produc- 
tion of casts in the urine, predisposing to serious and 
definite kidney lesions. From these findings I am con- 
strained to believe that a definite diagnosis of Bright's 
disease should never be absolutely made until the 
urinary findings aside from albumin and casts are nor- 
mal. (Since compiling these results my attention has 
been called to an interesting artide, from (which I 
quote: 'The occurrence of albumin in the urine, alone 
or associated with casts, is not the absolute indication 
of a nephritis, once believed, as we know that its pres- 
ence does not necessarily indicate an inflammatory 
lesion of the kidney. The subject of faulty metabolism 
as a cause of albuminuria is one which is attracting 
more and more attention, and deservedly so; for there 
seems but little doubt that this is the direction in which 
we must look for the etiological factors of at least one 
type of nephritis, the interstitial form.") 

This brings me to an important point. It is quite 
possible that, to a greater or less extent, the conditions 
found in the kidney known as chronic Bright's disease, 



A Study of the Urinary Acidity 95 

or interstitial nephritis, are in a measure due to those 
conditions which produce indican in the urine and high 
urinary acidity, and consequently the regulation of these 
conditions, the elimination of indican from the urine 
and the reduction of the acidity to normal should be 
distinctly valuable prophylactic measures. 

Another point of interest is that in the majority 
of cases, probably from 60 to 75 per cent., where the 
urinary acidity is excessive and indican is present, the 
urea elimination is invariably below the normal. From 
the findings in my 250 examinations the urea elimina- 
tion was reduced to an average of 60 per cent, of the 
normal (taking 30 grp. as the normal daily output) in 
as many as 81 per cent, of the whole series. Dr. 
Foxhail, in a very interesting paper in the London 
Lancet? has said that if the average urea excretion 
is below 1.4 per cent, for 10 or 15 days it nearly always 
indicates definite renal damage. And so from this it 
would seem that conditions under discussion — high 
urinary acidity and indicanuria, and the low urea- 
index — are very closely related, and have a definite ef- 
fect, the one upon the other. 

Right here I wish to emphasize the fact that the 
quantitative estimation of the normal substances ex- 
creted by the body through the urinary channel gives 
definite information as to the actual metabolic activ- 
ities of the body, which information should be of great 
value in the examination of the majority of those in- 
dividuals consulting the physician; while even the most 
careful examination of a complete 24-hour collection 



96 Essays on Laboratory Diagnosis 

for abnormal elements only assists in the diagnosis if 
certain definite disturbances are present, the frequency 
of which is not to be compared with the abnormal meta- 
bolic states which are unfortunately so very common. 

No one finding in the urine examination is of in- 
fallible diagnostic proof, as has already been stated 
regarding casts and albumin. Those laboratory facts 
which tell us of the exact status of the body functions 
are especially valuable when one is dealing with chrome 
conditions which do not prevent the patient from con- 
tinuing his usual vocation. This general idea of the 
extent of the metabolic functions of the body is un- 
fortunately very seldom known in the routine work of 
the average man. The test for albumin and perhaps 
sugar, in addition to the estimation of the specific 
gravity, is about all the "urine examination" usually 
done, and very rarely is a 24-hour collection demanded. 
Rather than forestall possible difficulties he advises a 
complete urinalysis only in extremis, and even then not 
too frequently. 

In this connection it might be well to quote from 
an excellent article by Dr. Cruise in the Lancet. In 
this article he says : "Every cautious physician exam- 
ines the urine for albumin in all serious cases of ill 
health, and not infrequently comforts himself and his 
patients when he finds that this substance is absent. I 
doubt that I am in error in adding, on the other hand r 
that very few practitioners attempt the quantitative es- 
timation of urea in such cases. Nevertheless the im- 
portance of ureametry is far greater than testing for 



A Study of the Urinary Acidity 97 

albumin alone, because while the latter is often present, 
and signifies little, and may be absent in very grave 
cases, the quantity of urea is a matter of serious and 
often vital consequence." 

And to this must be added that the estimation of 
the acidity will very quickly give an idea as to the 
general metabolic conditions of the patient, for, as has 
already been shown, this is nearly always associated 
with diminished urea. 

Regarding the collection of the specimen of urine 
several matters of importance require consideration. 
In order to get correct results it is necessary for a 
whole 24-hour specimen to be collected, care being 
taken to instruct the patient as to the proper method of 
doing this. During the collection the vessel should be 
kept in a cold place, and preferably five or ten drops 
of chloroform placed in the vessel to preserve the urine 
from fermentation. The test is then made as soon as 
possible after the receipt of the specimen at the labora- 
tory. 

Of course, some specimens will be alkaline in re- 
action, and in a majority of cases this will be found 
to be due either to retention of the urine, cystitis, or 
fermentation during the collection and transit of the 
specimen. The microscopic examination usually con- 
firms this by showing the presence of either pus cells 
and various forms of epithelial cells, or crystals of 
ammonio-magnesium phosphate, or both. If the above 
methods are carried out, practically no error will be 
caused from the lack of proper preservation of the 



98 Essays on Laboratory Diagnosis 

specimen. 

So far nothing has been said regarding the method 
of estimating the urinary acidity. As yet no one method 
is scientifically accurate, for since the acidity of the 
urine is not due to any one acid or acid salt, the selec- 
tion of a suitable indicator is a matter of considerable 
importance. . Different indicators vary greatly in the 
degree to which they are affected. Methyl orange, 
congo-red, etc., are more sensitive to the OH-ions of 
the alkalies, while phenolphthalein, rosolic acid, etc., 
are more sensitive to the H-ions of the acids. Litmus 
in its affinities occupies a place somewhere between 
these two groups. 

As has been stated before, the urinary acidity is due 
chiefly to the salt with the formula NaH 2 P0 4 , which 
reacts acid to phenolphthalein, the neutral point with 
this indicator not being reached until enough sodium 
hydrate solution has been added to convert this salt 
to that with the formula Na 2 HP0 4 . As a matter of 
fact, disodium-hydrogen phosphate, owing to dis- 
association into NaH 2 P0 4 and NaOH, reads faintly 
alkaline to phenolphthalein. It has been found that 
this can be diminished by the addition of a saturated 
solution of NaCl which is neutral in reaction and con- 
sequently cannot itself affect the reaction. That the 
addition of salt solution is of value can be proved by 
titrating to the point where the pink color just appears, 
and then adding the salt solution, when it will disappear. 

Salts with the formula Na 2 HP0 4 also exist in the 
urine, and these react alkaline to methyl orange and 



A Study of the Urinary Acidity 99 

congo-red, while those of the formula NaH 2 P0 4 are 
neutral to the same indicator. Consequently urine con- 
taining the above salts and which shows an acid re- 
action to phenolphthalein. when titrated with methyl 
orange as an indicator, will display an alkaline reaction, 
which is not destroyed until enough hydrochloric acid 
solution has been added to convert the salts of the 
mula Na 2 HP0 4 into those of the formula XaH 2 P0 4 . 
Any carbonate present must also be decomposed by the 
hydrochloric acid before the pinkish tinge indicat 
of the neutral point is reached. 

Litmus, which in the presence of the above men- 
tioned salts gives an amphoteric reaction, is absolutely 
useless in the titration of urine. A urine which shows 
a marked degree of acidity when titrated with 
phenolphthalein as indicator is often strongly alkaline 
to red litmus paper. Dr. Benedict, in his article, has 
well said: "The simplest way to deal with litmus is to 
discontinue it altogether, at least for such purposes as 
the present. All things considered, the best indicator 
for determining acidity not due to pure acids is phenol- 
phthalein, which, on the whole, places the neutral point 
about where it should be according to our general con- 
ception of acidity and alkalinity." 

The most satisfactory method of ascertaining the 
urinary acid-index is by titrating a definite quantity 
with an alkali solution of known strength, using 
phenolphthalein as an indicator. The technique is as 
follows : 

With a pipette or other measuring instrument meas- 



100 Essays on Laboratory Diagnosis 

ure out 10 c.c. of urine and add 2 or 3 drops of the 
indicator. To this add, drop by drop, from a burette, 
a decinormal sodium hydrate solution until a faint pink 
color is just obtained. (To those having no burette the 
use of the acidimeter is recommended.) The amount 
of solution required to give this reaction is read off 
and multiplied by ten, to reduce the figures to terms 
of 100 c.c. This is the acidity in degrees or per cent. 
This figure multiplied by the number of cubic centi- 
meters of urine passed in 24 hours gives the number 
of acid units passed. 

There are other methods of estimating the acidity — 
involving other principles. Some add an excess of 
potassium oxalate crystals to the urine before titration, 
believing that this makes the results more accurate, by 
ruling out error from the presence of ammonium salts. 
Others have various ways of expressing the acidity; 
some use terms of phosphoric acid, others terms of 
oxalic acid, and again others terms of hydrochloric acid. 
These methods all make considerably more figuring, and 
they also necessitate the use of an empirical alkali solu- 
tion which is standardized to equal a certain number 
of milligrams of phosphoric acid, etc. 

The above method gives us a very good idea of the 
acid elimination, and enables one to obtain therapeutic 
information which is of value. 

It must be remembered that the usual examinations 
made in quantitative urine analyses for medical pur- 
poses are all very crude when viewed from the strictly 
scientific standpoint. The hypobromite method, which 



A Study of the Urinary Acidity 101 

is probably the best method for the clinical estimation 
of urea, gives 6 to 8 per cent, error. The estimation 
of the specific gravity is rarely corrected to tempera- 
ture, and consequently varies quite a little from the 
actual specific gravity of the specimen; and the urinary 
acidity is probably from 5 per cent, to 10 per cent, 
away from the true figure if an ideal method could be 
devised for its estimation. But when the results are 
compared with the average of a large number of simi- 
larly obtained figures from normal individuals or with 
the estimations previously made on the same patient, it 
will be seen that approximate figures are distinctly val- 
uable because they give comparative information that is 
just what is needed in the practice of medicine. It is 
quite possible that it is because of the difficulties 
associated with the accurate estimation of urinary acid- 
ity that the matter has remained so much in the back- 
ground. 

The physician will not, of course, be as interested 
in the scientific side of this paper as in the help that it 
may afford him in obtaining results, and so a few words 
regarding the principles of treatment which seem to be 
indicated in those conditions presenting high urinary 
acidity and the associated conditions may not be amiss. 

It must be understood that the acidity of the urine 
varies in direct proportion with the alkalinity of the 
blood, and that in turn depends upon the general health 
and vital powers of the body. The normal blood-plasma 
is alkaline in reaction, due to the fact that it carries 
in solution certain alkaline salts, especially disodium 



102 Essays on Laboratory Diagnosis 

phosphate, Na 2 HP0 4 , and sodium carbonate. Upon 
this reaction depends, to a greater or less extent, the 
ability of the blood to absorb carbonic acid gas, and 
thus to carry on the good work of elimination by means 
of the lungs. 

When the normal alkalinity of the blood is dimin- 
ished and there is an excess of acid substances in the 
blood, an acid intoxication results which is called by 
some acidosis and by others acidemia. Both terms are 
correct, but since the word acidosis is almost invaria- 
bly associated with serious organic lesions, such as are 
present with diabetes mellitus, after chloroform anesthe- 
sia, and in other serious toxic states, I believe that the 
term acidemia is more appropriate for the condition 
which is under discussion at present. It is probable 
that the blood never becomes acid, as in such cases 
death would undoubtedly result, since the capacity of 
the blood for carrying excrementitious substances from 
the cells to the eliminative organs would be absolutely 
nil, and thus a general paralysis of elimination would 
occur. 

One function of the kidneys is to eliminate from the 
blood all excess of acid substances, and they are so 
constructed that they are able, not to filter, but to se- 
crete from an alkaline blood-plasma an acid urine. Now, 
if the amount of acid substances formed in the body 
metabolism is excessive, the kidneys frequently can no 
longer accomplish the work required of them, when 
the condition termed acidemia results. These harmful 
substances are carried around in the blood stream, neu- 



A Study of the Urinary Acidity 103 

tralizing to a greater extent the alkalies of the blood, 
and thus diminishing its power to carry carbonic acid 
gas, hence making a bad condition worse. 

It must be evident, therefore, that a diminished de- 
gree of the alkalinity of the blood-plasma, evidenced 
by increased urinary acidity, should be a danger signal 
of extreme value to the practitioner, as it is positive 
that an excess of acid products of metabolism in the 
blood is most harmful, and it should therefore be the 
duty of physicians treating such cases to attend care- 
fully to the modification of these particular conditions 
in addition to changing the causes of the abnormal me- 
tabolic functions. 

For some time French investigators have been treat- 
ing such diseases on the assumption that the reaction 
of the urine is a definite index to the state of the 
blood, and with excellent results. Their method of esti- 
mating the acidity is by Boussingault's titration method, 
using instead of sodium hydroxide a standard solution 
of calcium sucrate.( ?) Boussingault does not claim that 
his method estimates the exact quantity of acid present 
in the urine, but that it represents the physiological 
acidity — the acidity which is of interest to the medical 
man. 

In those conditions which have as one of their man- 
ifestations high urinary acidity, it has teen conclu- 
sively demonstrated that the judicious use of alkaline 
remedies is of distinct value. 

My friend, Dr. Eugene S. Talbot, of Chicago, has 
done much original work along this line, and has ac- 



104 Essays on Laboratory Diagnosis 

complished excellent results in the treatment of pyor- 
rhea alveolaris and other serious mouth conditions by 
simply cleaning the mouth thoroughly and neutralizing 
the general systemic hyperacidity with the suitable alka- 
line remedies, such as sodium bicarbonate, magnesia, 
etc. Twenty to forty grains of sodium bicarbonate dis- 
solved in water, with or without other synergistic rem- 
edies, is administered about one hour before meals and 
at bedtime. This very soon reduces the excessive acid- 
ity to normal. 

That this treatment is of value is evidenced by the 
resulting influence on the unpleasant conditions which 
are so commonly associated with the high acid-index. 
The mental dullness, many aches and pains, irritability 
and general restlessness, dyspepsia and biliousness, to- 
gether with the lowered vital resistance evidenced by 
frequent colds, etc., is modified, the patient begins to 
mend immediately, and the change is both favorable 
and marked. The alkalies should be given judiciously, 
and for not longer than a few days, and a careful watch 
over the urinary acidity made from day to day. This 
procedure, associated with the removal of the principal 
causative factors — intestinal putrefaction, constipation, 
indigestion, excessive feeding, the sedentary life in gen- 
eral — soon brings the patient to a more normal con- 
dition. 

Right here I can do no better than to quote from a 
very able article by Dr. Eustace Smith in the British 
Medical Journal as follows: " Alkalies when absorbed 
into the circulation increase the alkalinity of the blood, 



A Study of the Urinary Acidity 105 

modify secretion, and, if continued too long, may be- 
come a fruitful source of anemia and languor. Car- 
ried out through the kidneys, alkalies reduce or annul 
the acidity of the urine, and are at first beneficial, but 
in a moderate dose or in too protracted a course may 
cause cystitis or even vesical hemorrhage. The effect 
of alkalies is not alone limited to the local action on 
the stomach, for when used with judgment they seem 
to have the power of influencing the whole system for 
good and setting up a very favorable change, which is 
not always a merely transitory improvement. We often 
have occasion to notice the prolonged benefit which fol- 
lows a course of alkaline waters at one of the many spas 
both at home and abroad. Acting in this manner, the 
salts of the alkalies are not so much antacid as altera- 
tive drugs, which, given in moderate doses for a period 
of weeks and months, are able, without producing any 
immediate or striking change, to correct a morbid con- 
dition of an organ or of the whole system, and set up 
an improvement which, if not permanent, is slow to 
pass away. In addition to their value in derangements 
of digestion, alkalies are of special service in the treat- 
ment of urinary acidity and the discharge of sand and 
gravel." 

Careful investigation will prove that in the majority 
of chronic diseases, and especially in those diseases 
which are so very common, such as tuberculosis, rheu- 
matism, neurasthenia, etc., together with the hundred 
and one other conditions associated with autointoxica- 
tion, will usually show a decidedly high degree of acid- 



106 Essays on Laboratory Diagnosis 

ity, and also a marked increase in the number of acid- 
units eliminated per diem. When the conditions caus- 
ing this are modified and the findings in the urine 
changed, the chances of the patient for recovery are 
greatly increased, because the body and its cells do not 
have the extra work of getting rid of these poisons, 
and hence can better attend to the work of overcoming 
the ravages of the tubercle bacillus and of building up 
the body-structure in general. 

The study of the urinary acidity and its relation to 
disease is yet in its infancy, and it is to be hoped that 
in the future more time and effort may be expended 
on the investigation of this important subject. My sin- 
cere wish is that this paper may serve to arouse greater 
interest in this important matter. 

In closing, I will say that the time spent in making 
the quantitative acidity test as a routine will be more 
than repaid to the general practitioner in the indications 
for treatment he will receive from this information and 
the more satisfactory results derived from the better 
adjusted treatment. 



XI. 

ACIDEMIA AND AUTOINTOXICATION. 

Reprinted from 

AMERICAN MEDICINE, 
New York, 

January 1909 



CHAPTER XL 

ACIDEMIA AND AUTOINTOXICATION. 

These two most insidious and common diseases or 
conditions are especially serious because their onset is 
so often unnoticed and their progress unsuspected until 
material damage has been done. Usually found together, 
they are unfortunately becoming more common in this 
country. 

To speak more accurately, acidemia is one of the 
many forms of autotoxemia which finds expression in 
divers ways. All the various manifestations, however, 
give positive evidence of faulty digestive processes, in- 
active metabolism and incomplete elimination; and are 
caused primarily in many instances by hepatic insuf- 
ficiency. 

These diseases are found to a greater or less extent 
in sedentary men and women. In a series of urinary ex- 
aminations it is surprising to note how many specimens 
respond in a marked degree to the test for indican, and 
almost invariably present a high acidity. 

The first evidence of acidemia is usually a feeling 
of dullness or laziness, with an occasional headache. The 
individual complains probably of "not feeling well." He 
is, of course, not yet sufficiently inconvenienced to con- 
sult a physician, and the condition is allowed to gradu- 
ally become worse. The bowels are always quite irreg- 
ular in action, at times moving too freely and again 



110 Essays on Laboratory Diagnosis 

being moderately constipated. Later the breath becomes 
foul, the tongue coated, the stools bad smelling, often 
having an offensive, putrid odor, and in many patients 
dark rings form under the eyes. 

The effects on the temper are often marked, and per- 
sons previously kind, affable and agreeable become mo- 
rose and show "streaks" of ill-temper and rudeness. The 
mind is not as clear as before, and the afflicted individual 
often finds it hard to recall names or data that were for- 
merly quite familiar. Occasional pains are felt in vari- 
ous parts of the body, usually varying quite a good deal 
in severity and persistence. These may be ascribed to 
"a touch of rheumatism" or "just a little cold," and are 
naturally treated in a haphazard manner with little or no 
lasting results. Things go on from bad to worse until 
some neuralgia, arthralgia or other acutely painful con- 
dition causes the sufferer to demand the physician's at- 
tention. Should he be fortunate enough to secure a 
thorough physical examination, no serious conditions are 
brought to light, unless some other disease-process is 
also present. He receives, as a rule, a more or less brisk 
cathartic and is reassured by the usual "You'll be all 
right in a day or two." 

If, however, the urine should be examined, several 
important departures from the normal will be noted. 
The amount is usually diminished, the total acidity is 
found to be very high and the total solids low. The acid- 
ity shows an increase above the normal of 35 to 40 or 
even 100 per cent. The test for indican rarely shows its 
absence. 



Acidemia and Autointoxication 111 

The cathartic routinely given serves, of course, to 
eliminate a large amount of stagnant, putrefying ma- 
terial from the bowels, and, temporarily at least, the 
patient is made "better." However, if the cause of the 
trouble is allowed to persist, the previous conditions 
soon return, and the patient grows steadily worse. The 
stomach gets out of order, the appetite fails and the 
mouth conditions often become serious. Teeth decay 
rapidly, not from lack of care, but from the acid saliva 
that is invariably present. Neurasthenia, mental irrita- 
bility, the "blues," insomnia, neuritis, neuralgia, dyspepsia 
and a large number of other diseases are often encoun- 
tered, and the patient is apt to become sooner or later 
a nervous wreck. In this condition he goes from one 
physician's office to another without permanent benefit. 
At times he feels a little better, and again he is much 
worse, until at last he falls an easy victim to some seri 
ous disease, such as pneumonia, typhoid fever or tuber- 
culosis. 

From the foregoing it is evident that it is advisable 
in all cases to make a urinary analysis. Leube has well 
said : "I woud advise particularly never to omit the ex- 
amination of the urine in headache, even if it is of a 
purely intermittent character. We shall thus avoid sub- 
sequent self-reproaches. " 

The laboratory report will give definite grounds for 
initial rational treatment and the subsequent urinary ex- 
aminations will show the results of the treatment. The 
saliva, too, should be tested with blue litmus paper — a 
very easy procedure of considerable value which should 



112 Essays on Laboratory Diagnosis 

be carried out much more frequently in the routine of 
office or bedside consultations. The administration of 
salines, suitable hepatic stimulants and antacid remedies 
for an extended time, to be governed by the results on 
the urinary and salivary acidity, will in time regulate 
matters very satisfactorily. Intestinal antiseptics such 
as B-naphthol, the sulphocarbolates and other similar 
substances are of great assistance in reducing bowel 
putrefaction. The proteid rations should be materially 
reduced, especially the more easily putrefying meats. 

In closing, it may be well to add a few words. Most 
authorities deny that acidemia or autointoxication are 
diseases per se, and this is doubtless true. They are a 
serious menace to the average individual in that they 
lower the general vital resistance, making the patient 
much more susceptible to all diseases, infectious or not. 
The danger of these conditions is in direct proportion to 
their insidious onset. They should always be thought 
of when patients come complaining of obscure ailments. 
They are easily detected if the physician gives the proper 
weight to the laboratory findings and makes it a routine 
practice either to examine the secretions for himself or 
have it done for him by some competent laboratory 
expert. 

Once found and treated before the conditions have 
resulted in serious organic changes, the treatment is not 
only easy, but eminently successful, bringing new laurels 
to the man who thinks. 



XII. 
ACIDEMIA: SYSTEMIC HYPO-ALKALINITY. 

Reprinted from 

THE MEDICAL BRIEF, 
St. Louis, 

August, igio. 



CHAPTER XII. 

ACIDEMIA— SYSTEMIC HYPO-ALKALINITY. 

The whole of the vital economy hinges, as all know 
full well, upon the condition of the blood. "The blood 
is the life." 

For many reasons, of which the above is one, few 
subjects are of more actual clinical interest to the phy- 
sician than the study of the disease-resisting faculties 
of the human body. All diseases, and, indeed all our 
attempts to cure them, are in a large measure depend- 
ent upon the proper exercise of the metabolic functions 
of the countless millions of body cells. The matter, 
then, of the adequate elimination of waste and the proper 
neutralization within the organism of the poisonous 
substances manufactured during the processes normally 
carried out in the ordinary systemic activities, becomes 
one of paramount interest to us as physicians, for do 
we not depend upon the vital capacity of each cell, col 
lectively called the "vital resistance," for the effective 
carrying out of our therapeutic measures? 

One of the most important factors, which, it is be- 
lieved, should be more generally taken into considera- 
tion, is the alkalinity of the blood plasma; for there is 
unquestionably a very close relation between this fac- 
tor and the all-important interchange of gases carried 
on. The proper exercise of the oxygen intake and the 
carbonic-oxide elimination hangs upon the blood alka- 



116 Essays on Laboratory Diagnosis 

Unity, for it is essential that free alkali should be pres- 
ent in the blood in order that the loose chemical hemo- 
globin combinations can occur, which are so necessary 
to the efficient performance of the function of gas-inter- 
change. 

If this is true (and physiologists are unanimous as 
to the absolute necessity of a certain amount of free 
alkali in the blood), the immense import of the proper 
degree of blood alkalinity becomes quickly apparent. 
It is an unfortunate fact that only a very few physicians 
are studying this matter with the interest which its 
prime importance would seem to warrant. 

The study of the actual degree of blood alkalinity 
is no easy matter, even for the well trained expert with 
his costly and intricate apparatus ; and because of this, 
the estimation of the amount of titratable alkali in the 
blood serum is only rarely made. It so happens, how- 
ever, that one can gain a very good idea of the de- 
gree of systemic alkalinity by a study of the acidity of 
the urine. It is not unreasonable to suppose that the 
acidity of the urine is in close relationship, if not actu- 
ally in direct ratio, to the blood acidity, or rather alka- 
linity. This being the case, the tedious, expensive and 
altogether impossible test of blood alkalinity in the rou- 
tine of the general practitioner is rendered unnecessary, 
and in its place the very simple quantitative estimation 
of urinary acidity may be made. 

It is not claimed that the relation between the actual 
amount of free alkali in the blood and the amount of 
titratable acid in the urine is absolute and positive; but 



Acidemia — Systemic Hypo-Alkalinity 117 

experiment has shown that the fluctuations of the urin- 
ary acidity in health and disease have a very important 
influence over the bodily functions. The study of dia- 
betic acidosis, as well as of the metabolic changes which 
are so frequently brought about during and after chlo- 
roform intoxication, has conclusively shown that there 
is great danger to be anticipated from the presence of 
certain acid substances in the blood, of which oxy-bu- 
tyric acid and its congeners (diacetic acid and acetone) 
are the most readily appreciated in the laboratory. 

The acidosis referred to above is quite another mat- 
ter from the condition of systemic dealkalinization un- 
der discussion in this paper. For this reason the term 
"acidemia" is used in order that the distinction and evi- 
dent difference may be known. Suffice to say that acid- 
osis is a condition of systemic hyperacidity in which 
oxy-butyric acid or its congeners are always present; 
whilst acidemia is a systemic acidity (or hypo-alkalinity) 
which is far more frequently encountered and which 
does not show evidence of the presence of acetone in 
the blood or urine. This latter condition — acidemia — 
is not considered to be nearly as dangerous as the more 
generally known acidosis, for the simple reason that 
its far-reaching influence has not yet been appreciated 
to the full. It is, however, a dangerous condition, if 
for no other reason than that its altogether insidious 
onset and its treacherous influence are all too often not 
appreciated until some more or less serious condition 
calls the attention of the patient to a state of affairs 
that is far from easily righted. In other words, the 



118 Essays on Laboratory Diagnosis 

one-time simple, functional derangement has by then 
become a definite organic disease. 

It is claimed by some that the urinary acidity is of 
little or no importance because it cannot be accurately 
estimated. This may, indeed, be true; but one may be 
pardoned for disbelieving such statements when actual 
results — obtained hundreds of times — prove the con- 
trary. Realizing this, I unhesitatingly state that acid- 
emia or systemic hypo-alkalinity is a frequent, insidious 
condition, evidently due to some metabolic dyscrasia 
which is quickly and easily gauged by the estimation 
of the acidity of the urine; and which, because of its 
widespread occurrence, associated with almost every 
form of disease known, ought to be thoroughly under- 
stood by every physician, and its influence noted in con- 
nection with the study of every disease, from the com- 
mon cold to incipient tuberculosis. 

Experience has taught that this condition of acid- 
emia is, in the majority of cases, either actually due to 
or, at least, very closely associated with, intestinal auto- 
intoxication. One very frequently finds indican to ex- 
cess in urine showing a high acid-index. This is further 
exemplified in the fact that the successful, or, for that 
matter, the unsuccessful attempt at the removal of indi- 
can by the usual orthodox measures will cause a ma 
terial reduction in the urinary acidity, even though the 
diet remain the same and not one grain of alkali be 
given. Evidently, therefore, intestinal putrefaction is 
the one prolific cause of acidemia. This idea is not un 
reasonable when one remembers that indican (potas 



Acidemia — Systemic Hypo- Alkalinity 119 

sium indoxyl-sulphonate) is really an acid salt, and in- 
dol-acetic acid and the other associated toxins are acid in 
reaction. 

Another fact which goes to strengthen this conten- 
tion is that in cases evidencing urinary hyperacidity 
and indican, the urea index is usually very low and the 
amount of ammonia correspondingly high. This change 
in the relation of the substances eliminated in the urine 
is doubtless due to the fact that the excess of acid sub- 
stances in the blood has united with and neutralized 
the alkaline urea precursors and formed ammonia prod- 
ucts. It will be remembered that the amount of ammo- 
nia excreted in diabetes is usually enormous — for the 
selfsame reason. The body, in its attempt to neutralize 
the excess of acids formed through the faulty diabetic 
metabolism, eliminates as much of the acid as possible 
in combination with the much-needed systemic alkalies, 
the ammonia content being consequently very high; at 
times several grams per diem (0.7 gram in 24 hours is 
the normal). The resulting alkali-hunger makes bad 
very much worse, and can only be satisfied by the ad- 
ministration of alkalies. It is well known that the best 
treatment for diabetic coma is the intravenous injection 
of an alkaline solution, preferably of sodium bicar- 
bonate. 

The influence that acidemia has over the system is 
naturally very widespread. With the crippled gas-inter- 
change, the whole of the eliminative activities are disor- 
ganized. Toxic anemia is very common. Digestive dis- 
turbances, originally the underlying factor in the pro- 



120 Essays on Laboratory Diagnosis 

duction of this condition, are now rendered more com- 
plicated and unmanageable. The nervous equilibrium 
is disturbed, and we are just beginning to enter a realm 
of research which it is confidently believed will show 
a close connection between acidemia and many func- 
tional neuroses. Several severe eye disturbances, in 
eluding retinal hemorrhage, recurrent corneal ulcer, etc., 
have been seen with which the urinary hyperacidity 
had some close connection. 

Skin diseases are frequently found in the acidemic. 
The relation between alveolitis (pyorrhea alveolaris) 
and systemic hypo-alkalinity is demonstrated beyond a 
doubt. Many experiments have shown that the emunc- 
tories, among which the kidneys rank first, are badly 
crippled by the hypertoxicity of the urine, and it is 
pleasing to read that our contentions regarding the re- 
lationship between acidemia and incipient Bright's dis- 
ease have been positively proven. Roubitschek, in 
Berliner klinische Wochenschrift, May 2, 1910, relates 
the results of a series of experiments on rabbits in 
which he produced constipation by feeding oats and 
administering opium and tannic acid. In a week albu- 
men and casts were found in the urine. The albumen 
increased steadily to 0.50 pro mille. Autopsy after two 
or three weeks showed the liver and spleen hyperemic 
and the kidneys enlarged, dark red, normal consistence, 
and with capsule closely adherent. Punctiform hemor- 
rhages were present in the capsule and hemorrhages 
were also found in the glomeruli. 

Lastly, but most important of all, this condition 



Acidemia — Systemic Hypo-Alkalinity 121 

lowers the vital resistance and lays the unsuspecting 
individual open to infections and diseases of all kinds. 

If all the foregoing is true, the presence of an ex- 
cess of acid substances in the blood or a diminution of 
its free alkali, whichever term one chooses, should not 
only be looked for, but its untoward effects modified 
as quickly as possible. This is usually not a difficult 
matter to accomplish. Alkalies are cheap, easy of ad- 
ministration, and, when properly given, are practically 
harmless. Hence the therapeutics of the alkalies may 
well be given increasing attention, since their judicious 
use will produce a marked beneficial effect in these cases 
of acidemia. 

The treatment of acidemia does not, of course, con- 
sist in the mere administration of alkalies until the urine 
is of normal acidity. This would be purely empiric 
medicine. On the contrary, if worth-while results are 
desired in the treatment of this condition, the whole sys- 
tem must be thoroughly unloaded and a regular house- 
cleaning instituted. Besides the free use of salines, 
alone or following a dose of calomel or phenolphthalein, 
it is often well to look carefully for fecal impaction, 
especially at the flexures of the colon. If this is pres- 
ent, one or more high injections of oil may be given. 
Ordinary "sweet oil" serves the purpose well, but the 
addition of 1 per cent of icthyol considerably increases 
the efficiency of this treatment. Four to six ounces are 
injected as high as possible into the colon; the patient 
is instructed to lie with hips raised and the clothes or 
bed carefully protected. If the oil can be retained all 



122 Essays on Laboratory Diagnosis 

night, so much the better. 

Tonic measures may or may not be given, depend- 
ing entirely upon the circumstances present in each 
case. Physical measures are of immense value. The 
sinusoidal current to the abdomen, interrupted galvan- 
ism, and even faradism, are of service. Abdominal manip- 
ulation and exercise with or without resistance are use- 
ful. Prolapse of the viscera should always be corrected ; 
and this will be found to be very frequently necessary. 
Tonic hydrotherapy (hot and cold applications, douches, 
etc.) to abdomen, liver and spine are helpful. In fact, 
anything that will serve to enable the abdominal walls 
and bowel musculature to regain their normal tonicity 
and vigor will be of service. 

The alkalies may well be combined with other syn- 
ergistic remedies. Several formulae have been in use 
for some time. One of them, suggested by Doctor E. 
S. Talbot, now goes under the name Sodoxylin (Ab- 
bott) and has the following formula: 

Sodium Bicarbonate . . . gr. xx 

Sodium Sulphocarbolate . . . gr. ijss 
Sodium Sulphate .... gr. v 

Colchicine gr. 1-500 

Xanthoxylin gr. 1-6 

Sugar, Aromatics, Etc. . q. s. ad gr. lx 

Sig. : One teaspoonful two or three times a day be- 
tween meals and with plenty of water. 

Another formula might be mentioned: 

Sodium Bicarbonate gr. xxv 

Sodium Sulphocarbolate . . . gr. x 
Phenolphthalein . . . . gr. ss 

Sugar q. s. ad gr. lx 



A cidemia — Systemic Hypo-A Ikalinty 123 

Sig. : Make in powder or granular form. Take a 
teaspoonful, followed by a large draught of water (hot 
or cold) between meals. 

Still another therapeutic measure which must not be 
forgotten is the use of living cultures of certain lactic 
acid bacilli. Massol's bacillus, or the Bacillus bulgari- 
cus, seems to have a decidedly beneficial action in these 
cases, and its use cannot be too highly recommended 
if the cultures are virile and enough of them are given. 

In closing, it might be well to mention a combina- 
tion of conditions that may put the physician off his 
guard and bewilder him in his study of these cases of 
acidemia. In a number of instances it will be found 
that the patient is evidently suffering from toxemia 
with all the usual symptoms, including headache, ma- 
laise, bad breath, anemia, indicanuria and the hundred 
and one associated disturbances ; but the urine is almost 
alkaline. One must here exclude the possibility of alka- 
line fermentation of the urine either in vivo or in vitro. 
Eliminate the possibility of cystitis or retention. Keep 
a little chloroform or other preservative in the specimen 
from the commencement of its collection in a covered 
vessel. Then carefully watch the patient and the vari- 
ations of the acidity from day to day. It will be fre- 
quently found that there comes a crisis or period in 
which the physical symptoms are materially worse. The 
patient is prostrated with fever, chills and general dis- 
disability, and the acidity is tremendous. 

In these cases, instead of eliminating as much of the 
effete matter as possible, the patient is storing up the 



124 Essays on Laboratory Diagnosis 

poisonous products in his system until the body makes 
a special effort to right matters and the so-called "crisis" 
comes. In such cases the treatment should evidently 
be exactly the same. The clean-out treatment, the tonic 
measures and the alkaline draughts will serve to reduce 
the rate of manufacture of the toxins and neutralize 
them in the tissues before they get into the blood and 
thence through the kidneys to increase the acidity of 
the urine passed. 

Such cases have proved a stumbling-block to many 
beginners in the study of acidemia and its clinical value ; 
but the investigation of a few cases for a week or two 
will convince one that this condition of retained waste 
is even worse than when the acidemia is plainly noted 
by a study of the urinary findings. 

Acidemia is far too important to t)e longer over- 
looked. Probably your next patient has it. Try the 
test and see. 



XIII. 

THE RELATIONS AND CLINICAL SIGNIFI- 
CANCE OF THE URINARY ACIDITY. 

(A paper read before the Illinois State Medical Society, Danville^ 

May, 1910.) 

Reprinted from 

THE ILLINOIS MEDICAL JOURNAL, 

Springfield, 

October, igio. 



CHAPTER XIII. 

THE RELATIONS AND CLINICAL SIGNIFI- 
CANCE OF THE URINARY ACIDITY. 

One is tempted to believe, from a study of the liter- 
ature on this particular subject, that it is of little or 
no significance. In fact, very little space is devoted 
in most text-books to the discussion of the importance 
of the urinary acidity. One learns that the reaction of 
the urine is normally acid, that at certain times of the 
day it may be amphoteric or even alkaline, and that an 
alkaline urine is in all probability an evidence of cystitis 
or retention. The litmus paper test is referred to, the 
burette method of estimating this factor is mentioned, 
and, generally speaking, the whole subject is passed by 
very superficially. In addition to this, current medical 
literature has until the last year evidenced a decided 
paucity of discussion along this line. It is encour- 
aging to notice that as medicine progresses a greater 
interest is being manifested in the so-called "minor mat- 
ters" and the study of the urinary acidity and its rela- 
tions will soon be considered in its proper light. 

The information obtained by the careful estimation 
of the urinary acidity is of very great clinical import. 
In my estimation it is one of the most important of the 
urinary findings and a factor which should be known 
as a matter of course in the routine examination of 
every case; for the conditions associated with a de- 
creased blood alkalinitv have been found time and 



128 Essays on Laboratory Diagnosis 

again associated with several other definite findings, and 
it has been shown by laboratory experiment, as well as 
by clinical experience, that therapeutics based on this 
particular finding have given most salutary results. 

The reason 'that the condition of high urinary acid- 
ity and the usual associated clinical and laboratory find- 
ings have not been more frequently found and described 
together is that they have been seldom looked for. The 
determination of the reaction of the urine by the obso- 
lete litmus method is as far as most physicians care 
to go in their urinalyses. The degree of acidity is esti- 
mated in the larger clinical laboratories, but it is the 
exception rather than the rule to find the averge phy- 
sician taking the time or trouble to make this simple 
test. "What good is it, anyway?" they say. "If I can 
see a specimen of urine and make a test for albumin 
and sugar, and find out the specific gravity, I'm satis- 
fied." 

This is an unfortunate state of affairs, for the acid- 
index is a factor of considerably more than ordinary 
importance, has a direct and close relation to metabolism 
and elimination, and is, therefore, a guide of no mean 
value to the physician who is endeavoring to care for 
indefinite and obscure ailments. 

The estimation of the urinary acidity is not a diffi- 
cult procedure. It can be very simply and quickly esti- 
mated in the laboratory with a burette, or anywhere 
with an acidimeter and no other reagents than deci- 
normal soda solution and a phenolphthalein indicator 
solution. Some writers have said that this test is far 



The Relations of the Urinary Acidty 129 

from accurate and for this reason have depreciated it. 
There is not a doubt of the futility of endeavoring 
to accurately estimate the total acidity by the above 
method; but in clinical laboratory work we do not ex- 
pect a grade of volumetric or gravimetric work which 
can be compared, say, to the work of the assayer or 
metallurgist. In medicine we are satisfied with approx- 
mate figures. To prove this, I merely mention the 
notoriously inaccurate methods in general use for the 
estimation of albumin, urea and, for that matter, prac- 
tically every quantitative urinary test save alone the 
estimation of nitrogen. 

The fact that the actual total acidity of the urine is a 
factor which is practically impossible to obtain with any 
absolute degree of accuracy does not deter the practical 
physician from making the test. Let us give here an 
illustration. A specimen is examined and the acidity 
is determined to be 40 degrees. The amount passed is 
one liter. The reaction to litmus is, of course, acid. A 
second specimen is examined and the acidity found to 
be 120 degrees with an amount approximating 1,500 c.c. 
The litmus test is also acid. Is there any material dif- 
ference between the condition of the alkalinity of the 
blood in these two cases? Assuredly. In the first case 
the number of acid units is 40,000 (practically the aver- 
age normal figure) and in the second, 180,000, or a 
good deal more than four times the normal. Surely 
there is an evident difference here. 

Personally, I have encountered no little skepticism 
regarding the real clinical importance of the matter un- 



130 Essays on Laboratory Diagnosis 

der discussion here. I presume that this is only nat- 
ural. Too often we are prone to overlook the more 
common things simply because we do not realize their 
significance. The "theory of autointoxication/' first 
taught by Bouchard, has within twenty years become 
one of the most important and widely recognized fac- 
tors in the pathogeny of all disease, and yet the eminent 
internist and investigator, von Noorden, himself, admits 
that: "At first we German physicians were by no means 
inclined to accept the theory of autointoxication that 
was being so enthusiastically proclaimed. Of late years, 
however, our attitude has become more friendly to the 
doctrine. This change of front is due to the fact that 
a number of the toxic products of metabolism have 
actually been isolated and their mode of origin in the 
organism, and their pathologic efifect determined to 
the satisfaction of the former critics." 

If I am not greatly in error, the clinical significance 
of the urinary acidity will be in the years to come one 
of the essential diagnostic factors. It will be estimated 
in every case and, to a certain extent, upon its varia- 
tions will depend the rational treatment of the majority 
of diseases. 

In a paper which I wrote in the spring of 1909, and 
published in the Medical Record early in June of that 
year, I gave the results of a series of about 250 urin- 
alyses which proved, to me at least, that there was a 
close relationship between excessive urinary acidity and 
indicanuria. My work since then, as well as that of 
a number of friends and correspondents, has only served 



The Relations of the Urinary Acidity 131 

to corroborate this finding. Evidently the condition 
which is known to cause the presence of indican in 
the urine is also responsible for a marked increase in 
the acidity. In the above paper I also called attention 
to the fact that practically 25 per cent of the whole se- 
ries showing excessive acidity also evidenced casts, usu- 
ally of the hyaline type, and, at times, traces of albumin. 
It is pleasing to note that investigators elsewhere are 
corroborating these findings. Von Hoesslin states that 
albuminuria and cylindruria are in some cases directly 
dependent upon the acidity of the urine. In these cases 
albumin and the formed elements disappear entirely or 
diminish in degree if the urinary acidity is decreased 
by the administration of sodium bicarbonate. He be- 
lieves that it is necessary to determine the relationship 
of all albuminurias to the existing acid-index. 

Another very common disturbance in the relations 
of the urinary findings is that with an excessive acidity 
there is frequently found a markedly lowered urea- 
index. The total solids are decreased in some cases 
as low as one-third of the normal. This shows conclu- 
sively that urinary hyperacidity is associated directly 
with the metabolism. The urea-content is diminished 
because the urea-precursors are neutralized by the ex- 
cess of abnormal acid substances in the blood and elim- 
inated as ammonia compounds. As a result, the amount 
of ammonia in the urine is usually excessive in these 
cases. Then, again, since the solids are often so de- 
cidedly diminished, it would seem that the organism is 
storing up trouble for itself in the form of the effete 



132 Essays on Laboratory Diagnosis 

metabolic products which should normally be elimina- 
ted. This seems to be proved true by the not infrequent 
"crises" in which the individual who for weeks and 
months has been eliminating much less than the normal 
is suddenly taken seriously ill and the urine shows not 
only a tremendous acidity (265 degrees was, I believe, 
the highest figure seen in my laboratory), but the solids 
are also markedly increased. Naturally, in these cases 
there are abundant evidences of renal irritation. 

It may not be out of place here to call attention to 
the fact that upon the normal alkalinity of the blood de- 
pend two of its most important functions — oxygen-car- 
bon-dioxid exchange and phagocytosis. Any condition or 
combination of conditions which would tend to decrease 
either of these powers must evidently have an import- 
ant and widespread influence upon the general disease- 
resisting capacity of the organism. Acidemia, or di- 
minished blood-alkalinity, will be found in practically 
all chronic diseases and, for that matter, in many acute 
diseases; and it is confidently believed that this factor 
of urinary hyperacidity is of sufficient importance to 
be known and its variations carefully watched in all 
cases. One can quickly corroborate these statements by 
making an examination of the urinary acidity of a twen- 
ty-four-hour specimen, of course, in the most frequently 
encountered condition of lowered resistance, the com- 
mon cold. The acidity is almost invariably increased; 
and, what is of more importance, demonstrating even 
more conclusively that this matter is worthy of consid- 
eration, the administration of alkalies will do much to 



The Relations of the Urinary Acidity 133 

favor the breaking up of the cold. 

I could enumerate case after case in which the urin- 
ary findings and ultimate outcome proved unquestion- 
ably that acidemia is a condition worthy of careful 
consideration. Two or three will suffice here: A col- 
league, while visiting in Seattle, was invited to see a 
case of severe throat ulceration which was interesting 
because of the extent of the disease and its intractability. 
The little girl had been for several weeks suffering with 
a membranous condition of the throat and pharyngeal 
walls which was becoming progressively worse. Heroic 
doses of diphtheria antitoxin, swabbings with silver ni- 
trate solution and the best treatment that one of the 
leading specialists could afford seemed without avail. 
My friend asked if the urine had been examined. No. 
Might it not be done at once? Certainly. A specimen 
obtained in the office and tested in the acidimeter 
showed an acidity of nearly 180 degrees. A twenty- 
four-hour specimen which was begun immediately was 
tested the next day and the acidity found to be practi- 
cally the same. The case was treated with a sodium bi- 
carbonate mixture until the acidity of the urine was 
normal, and within a few days the membrane and every 
evidence of the condition had disappeared save a 
marked hyperemia of the pharynx. 

Again, a prominent business man in Washington, 
D. C, was suffering from a nervous condition which had 
baffled a number of the best physicians there. He acci- 
dentally came under the notice of a friend of mine 
and it was suggested that the urine be carefully exam- 



134 Essays on Laboratory Diagnosis 

ined. It was found to be excessively acid, and the com- 
monly-occurring associated findings mentioned before 
were also thoroughly in evidence. To make a long 
story short, the sufferer, who had almost given up hope, 
was treated as an acidemic, and within a few weeks was 
another man. This sounds almost like a patent medicine 
story; but it is not. 

Still another case which I have watched personally 
for considerably over a year. A young man was suffer- 
ing from epileptic seizures. When I was consulted, the 
urine was, of course, examined. It was found to be 
excessively acid, much indican was present, and the 
solids were very low. The_ acidity was reduced, the 
indican eliminated, and, to make another long story 
short, the seizures ceased, to return only when the con- 
ditions were not as carefully watched as they should 
have been. The only treatment has been to keep down 
the acidity and to prevent (the circumstances which 
caused it. In about eighteen months there have been 
only two or three attacks and the urine passed before 
and after them was excessively acid and toxic. 

In discussing this subject last summer with Dr. 
Frederic E. Sondern, of New York, he made a remark 
which will bear repetition here. In answer to a ques- 
tion concerning the difference between "acidemia" and 
"acidosis," he said that B-oxybutyric acid or its con- 
geners was an essential to true acidosis. This, then, 
shows that there is a decided difference between the 
acid-condition of diabetes mellitus and the condition 
called acidemia now under discussion. The treatment 



The Relations of the Urinary Acidity 135 

may be essentially the same, and, for that matter, a part 
of the underlying cause the same, but the two condi- 
tions are essentially different and must not be con- 
fused. 

Doctor Sondern also said that it would be some- 
thing worth while if the "acid-substances" which evi- 
dently cause this troublesome condition could be iso- 
lated and named. Possibly this may be accomplished 
later, but in the meantime we must be satisfied with 
knowing that they are there and that their presence 
warrants attention. In all probability these "acid-sub- 
stances" are closely related to the sulphuric acid prod- 
ucts of intestinal putrefaction, to indolacetic acid, in- 
dican and skatol. For clinical purposes, however, it is 
not always absolutely necessary to know the definite 
scientific name of the causus mali. The fact that it is 
there and the means known whereby its effects can be 
counteracted is more than enough for all practical pur- 
poses. 

It might be well here to give the principal factors 
which cause variations in the reaction of the urine. 
The acidity is increased by autotoxemia, fever, dimin- 
ished output of urine, the ingestion of an excess of 
proteid food and certain more or less obscure metabolic 
disturbances, among which diabetes melUtus stands first. 
On the other hand, the main factors causing a dimin- 
ished acidity of the urine are alkalies taken internally, 
the ingestion of fruit acids, cachexia or a marked dim- 
inution in the metabolic activities of the body, and 
diuresis. It is well to remember that diuresis decreases 



136 Essays on Laboratory Diagnosis 

the acidity of the urine and that the decrease is pro- 
portional in degree to the extent of the diuresis, no 
matter how the increased flow of urine is brought about. 
One other important factor must not be overlooked. 
Any circumstance which causes fermentation of the 
urine, no matter whether in vivo or in vitro, will reduce 
its acidity. For this reason, when cystitis or prostatitis 
is present, due allowance for these conditions must be 
made. Again, the urine should be examined as soon 
after the collection as possible, and steps taken to pre- 
vent the onset of the usual ammoniacal fermentation 
for obvious reasons. 

It would seem, from the foregoing, that the follow- 
ing conclusions might properly be drawn: 

1. The study of the urinary acidity and its rela- 
tions is worthy of much wider attention. 

2. Its clinical significance is of importance in all 
disease -conditions, but more especially in the indefinite 
and obscure chronic diseases. 

3. The acid-index is a factor of considerably more 
importance than has yet been supposed, and has an inti- 
mate relation with the phenomena .commonly found 
with intestinal putrefaction and autotoxemia. 

4. The urinary acidity is not only of importance 
in diagnosis, but also serves as a valuable guide during 
the period of treatment. 

5. The frequent finding of evidences of kidney 
irritation would lead us to believe that the conditions 
causing urinary hyperacidity are important predisposing 
factors in the causation of nephritis. 



The Relations of the Urinary Acidity 137 

6. The test for the degree of acidity is simplicity 
itself and can be easily accomplished either with a bu- 
rette or an acidimeter. 

7. The clinical indications and therapeutic possibili- 
ties suggested by these findings will more than repay 
one for the slight trouble required in making the tests. 



XIV. 

THE URINARY AMMONIA IN ROUTINE 
WORK. 

Reprinted from 

THE MEDICAL COUNCIL, 
Philadelphia, 

January, ign. 



CHAPTER XIV. 

THE URINARY AMMONIA IN ROUTINE 
WORK. 

I believe I am not overstating when I say that not one 
pro mille of the men now doing clinical laboratory work 
in general practice — certainly not one per cent — are mak- 
ing the quantitative test for ammonia in the urine as a 
routine. The reader will quickly be able to decide in 
his own particular case whether I am right or not. 

There are two great reasons for this state of affairs: 
It is not known how easy the test is, and how little time 
and skill it takes ; and its advantages in general practice 
are not appreciated nearly as much as their importance 
really warrants. 

It will be my endeavor in this paper to call attention 
to the simplicity and accuracy of the so-called Malfatti- 
Rongese test, to compare it with the expensive and 
tedious Folin test now commonly used in the larger lab- 
oratories and to give good and sufficient reasons why 
the general practitioner should take any of his valuable 
time in carrying out the test and making the calculations. 

To begin with the latter consideration: The urinary 
ammonia index is an excellent guide to the resisting 
powers of the organism against certain toxemias, af- 
fording us very definite evidence of an autointoxication 
by certain organic acids. The repetition of a few facts 
which the physiological chemists have found out for us 
will quickly explain why this factor is the important 



142 Essays on Laboratory Diagnosis 

clinical and prognostic guide it is claimed to be here. 

Ammonia is one of the most important products of 
proteid metabolism. Urea, the most important of the 
urinary solids, consists of a combination of nitrogenous 
metabolites, among which ammonia is prominent; urea 
being, chemically, ammonium carbamide (CH 4 N 2 0). It 
has been definitely learned that the substances which 
go to form urea are combined in the liver. Extensive 
animal experimentation has shown that the arterial blood 
of animals contains approximately 0.4 milligrams of am- 
monia, as compared with a corresponding 1.85 milli- 
grams in the portal blood. These substances before they 
reach the liver are termed "urea precursors," and, it must 
be understood, are alkaline in reaction. 

When the blood is charged to an abnormal degree with 
the acid wastes formed during the putrefaction of nitro- 
genous materials in the intestines, and also in a dis- 
ordered metabolism, in the wise economy of Nature they 
are promptly combined with the alkaline urea-precursors, 
thus rendered neutral and practically harmless, and ex- 
creted in the form of other ammonia compounds in place 
of urea. Hence one can readily see that a markedly in- 
creased ammonia index shows us that there is an increase 
in the amount of acid in the blood, or rather, an increase 
in the amount of these acid substances being produced. 
Besides this, we learn that the body is performing its 
work as best it can under the unfavorable circumstances 
by neutralizing these acids as fast and as thoroughly as 
possible, and maintaining, as nearly as it can, the normal 
blood alkalinity. An increased ammonia index, there- 



The Urinary Ammonia in Routine Work 143 

fore, tells us whether there is a tendency toward acid- 
emia, and to what extent; whether the body is handling 
this disturbance aright and calls for the administration 
of other alkalies to take the place of the urea-precursors, 
and thus allow them to be normally combined to form 
urea and eliminated as such. 

Normally there is only a small amount of ammonia 
passed daily. The figure varies with the diet, being 
•usually a little less than one gram per day, probably 
nearly 700 milligrams. This represents a percentage of 
about 0.054 per cent, /. e., 540 milligrams of ammonia 
per liter of urine. This corresponds to between 4 and 5 
per cent of total nitrogen. 

From the foregoing it will be seen that the ammonia 
index can be made of not only diagnostic and prognostic, 
but of really therapeutic value in many cases — so many, 
in fact, that it is best to make this test a part of the 
every-day urine examination. 

In one disease this figure is probably of as great im- 
portance as any of the urinary findings. In diabetes 
mellitus I believe that the ammonia index ranks equally 
with the acetone and diacetic acid tests, and far outranks 
the quantitative estimation of the glucose which may 
or may not be present. It is now thoroughly understood 
that in diabetes it is not so much the amount of sugar 
passed that endangers the life of the patient, but rather 
the amount of acids produced in the tissues due to the 
perverted diabetic metabolism, which when carried into 
the blood depletes its normal alkali content and tends 
toward systemic hyperacidity (acidosis) and the fatal 



144 Essays on Laboratory Diagnosis 

coma. In these cases the ammonia index is, of course, 
very high, frequently reaching to 3 or 4 or even more 
grams per day. This high figure shows how thoroughly 
these abnormal diabetic acids are being neutralized and 
is naturally an evidence of serious impending danger. 

In certain diseases of the liver, notably hepatic cir- 
rhosis, acute yellow atrophy and carcinoma (any condi- 
tion in which the liver cells are degenerated), this com- 
bination of the urea-precursors is not always properly 
effected, since the liver cells are unable to perform their 
functions, and as a result the ammonia percentage rises 
at the expense of the urea — the total nitrogen being con- 
sidered as remaining constant. 

Considerable work has been done by certain investi- 
gators on the underlying causes of the various obscure 
toxemias, especially the toxemias of pregnancy, cachexia 
due to cancer and the severe anemias, and the changes 
in the metabolism coincident with them. In these dis- 
eases the ammonia index is often very much increased, 
and thus points us to needed treatment — judicious alkali 
administration. Other factors increasing the ammonia 
in the urine are: 1. The ingestion of inorganic acids 
and of organic acids which cannot be thoroughly oxi- 
dized. 2. The ingestion of much fat (due probably to 
the disassociation of a part of the fat into fatty acids). 
3. Oxygen starvation and fevers. 

From a personal communication from Dr. G. C. Math- 
ison of University College Hospital, London, I extract 
the following paragraphs, as they have a direct bearing 
upon the subject under discussion, and contain several 



The Urinary Ammonia in Routine Work 145 

important facts put in language which cannot well be 
mistaken : 

"Of course, the relation of ammonia to urea is val- 
uable, almost as valuable as ammonia to total nitrogen, 
for where the ammonia has increased, it is generally 
at the expense of the urea. 

"The urea-nitrogen, which one obtains by multiplying 
the urea by 28/60, is usually from 85 to 90 per cent of 
the total nitrogen; the ammonia nitrogen (14/17 of the 
ammonia) is usually from 4 to 5 per cent of the total 
nitrogen. Urea determined by any good ureometer, such 
as the Doremus instrument, is quite accurate enough. 
Thus the relation may be expressed: ammonia-nitrogen: 
urea-nitrogen: :1 :18. If this ratio rises to 1 :10 it is very 
suspicious ; if to 1 :6 it is distinctly pathological. Over 
1.5 grams of ammonia per day is very suspicious; over 
2 grams distinctly pathological. A good normal figure 
is 0.7 grams. 

"It is, I think, well established that urea-precursors 
are fixed by acids so that urea is lessened and ammonia 
is increased. It must be remembered that the figures I 
have given only apply where the patient is getting a 
fair protein diet, such as 'full hospital diet.' If, as in 
many toxemias, vomiting is present, the patient may 
really be ingesting an insufficient amount of food. This 
I rather suspect to be often the case in the toxemias of 
pregnancy, where increased output of ammonia is re- 
ported. Also, the ingestion of large quantities of acid 
will cause an increase in the ammonia output." 

Regarding the test for ammonia in the urine in gen- 



146 Essays on Laboratory Diagnosis 

eral practice quite a good deal might be said, but I will 
confine myself to the explanation of the formalin method 
first described by Malfatti and Rongese, which is by far 
the simplest and best test. As compared with the Folin 
test it has several points of superiority: 1. In accuracy 
it is practically the equal of the Folin test. 2. It re- 
quires no extra and expensive apparatus. 3. It occupies 
two or three minutes instead of three hours or more. 
4. With one additional reagent (very easily obtained) 
and a minimum of time it can be added to the routine 
urine examination. 

The test is as follows : First estimate the urinary acid- 
ity of 10 c. c. or more of urine by the titration method 
using decinormal soda solution and phenolphthalein in- 
dicator (y 2 to 1 per cent in 50 per cent alcohol). Then 
add two or three c. c. of neutral formalin (no absolute 
amount is needed save enough to produce the reaction) 
— a 20 per cent solution of commercial formalin to which 
a few drops of phenolphthalein indicator have been added 
— and enough alkali to make it just faintly pink. Al- 
most immediately the pink color formed as the end-result 
of the acidity test disappears, due to the disassociation of 
the ammonia present, combined with acids. The am- 
monia unites with the formalin to form hexamethylene- 
tetramine, while the acid previously in combination with 
the ammonia is set free, thus discharging the pink color- 
ation of the mixture. More decinormal soda solution is 
now carefully added until the pink color returns. The 
amount of decinormal soda solution in c. c. required to 
produce the second pink coloration represents the urin- 



The Urinary Ammonia in Routine Work 147 

ary acidity which has been passed in association with 
ammonia, which factor is used in the determination of 
the ammonia index. All that remains to be done is to 
multiply this last figure by an arbitrary factor which has 
been found to represent the amount of ammonia in each 
c. c. If 10 c. c. was the amount of urine used in the 
test, this factor is .00068; if 20 c. c. was used, it is .00136, 
and if 25 c. c, it is .0017. 

Some have advocated the addition of 10 or 15 grams 
of powdered potassium oxalate before titration in order 
to sharpen the reaction, but for general purposes the 
writer considers that this need hardly be done. 

In a paper published a year or more ago in the Xew 
York Medical Record I described an instrument for the 
rapid estimation of ammonia in the urine, and there 
called it an "ammoniometer/' It was essentially a mod- 
ification of my acidimeter and was arranged so that pow- 
dered potassium oxalate could be added as a part of the 
test. In my estimation, this has detracted from the prac- 
ticability of the above instrument. On the other hand, 
a large number of tests made with my small acidimeter 
have shown me that it may be used for this test in ques- 
tion, as well as for the estimation of the urinary acidity. 
The only suggestion or modification that I would make 
is that the tube be made y 2 or yi inch longer and grad- 
uated to 150 degrees instead of to 100 degrees as at pres- 
ent. The technique for the use of this instrument would 
be: Fill the tube with urine to the 10 c. c. mark; add 
two drops of indicator, and then slowly add the alkali 
solution, inverting from time to time to mix it, until a 



148 Essays on Laboratory Diagnosis 

pink color is just produced. The acidity in degrees is 
now noted, and two c. c. (20 degrees) or more of the 
neutral formalin solution added. (Note: — It is well to 
add the formalin to an even number or level on the 
tube.) Having marked down the level of the fluid in 
the tube at this juncture, carefully add as before the soda 
solution until a pink color just appears for the second 
time. Each ten degrees (one c. c.) of solution used to 
cause the return of the pink color represents .00068 
grams of ammonia in ten c. c. To find the percentage 
one multiplies by 10 ; and to find the amount of ammonia 
in 24 hours, multiply by the amount of urine passed in 
c. c. divided by 10. 

The use of the acidimeter in preference to the burette 
method in office work is recommended because of its 
greater ease, cheapness and simplicity. The two factors 
learned in the completed test — the urinary acidity in de- 
grees and the ammonia index — are certainly of immense 
clinical significance. The careful physician will many 
times find that these two figures alone are indications 
for treatment which will be found to aid materially in 
securing needed therapeutic results, and incidentally in 
adding to one's professional prestige with a minimum of 
time, bother and expense. 

To give some comparative figures of a number of tests 
made by the long Folin method and the short Malfatti 
method, I append here the results of seventeen carefully 
made tests, which show that the figures obtained from 
the Malfatti test are usually slightly higher than those 
from Folin's test. This is probably due to the fact that 



The Urinary Ammonia in Routine Work 149 

the addition of the formalin liberates not only the acids 
combined as ammonia, but also disassociates the amido- 
acids. It will be noticed that these comparative figures 
include a number of cases in which acetone, diacetic acid 
and oxybutyric acid were present. 





Grams of 


ammonia 




Amt. of urine 


— in 24 hours— 




in 24 hours. 


Folin. 


Malfatti. 


Remarks. 


400 c.c. 


.483 


.496 


Normal. 


420 c.c. 


.459 


.491 


Normal. 


620 c.c. 


.280 


.319 


Normal. 


3,260 c.c. 


3.884 


4.057 


All diabetic acids. 


1,475 c.c. 


3.891 


3.975 


All diabetic acids. 


860 c.c. 


3.22 


3.31 


All diabetic acids. 


3,030 c.c. 


3.927 


3.899 


All diabetic acids. 


3,280 c.c. 


3.790 


3.635 


All diabetic acids. 


975 c.c. 


.538 


.622 


Acet. and diacetic. 


640 c.c. 


.662 


.683 


Acet. and diacetic. 


690 c.c. 


.433 


.483 


Acet. and diacetic. 


490 c.c. 


.236 


.312 


Normal. 


1,500 c.c. 


.636 


.643 


Sugar ; no acetone. 


600 c.c. 


1.128 


1.265 


All diabetic acids. 


700 c.c. 


.44 


.477 


Sugar ; no acetone, 


500 c.c. 


.284 


.316 


Sugar ; no acetone 



XV. 

THE COLLECTION OF THE URINARY 
SPECIMEN. 

Reprinted from 

THE MEDICAL STANDARD, 
Chicago, 

September, 1909. 



CHAPTER XV. 

THE COLLECTION OF THE URINARY 
SPECIMEN. 

To some it may hardly seem necessary or appropri- 
ate to take time or space for the discussion of this 
matter, but a more or less extended experience seems 
to indicate that the subject could well stand being re- 
ferred to here. 

The usual haphazard qualitative tests of a specimen 
of urine voided at random are rarely of much value, 
at least as far as giving any definite information as to 
the metabolic condition of the individual. Rarely a sim- 
ple test quickly done may give some information, but 
this is usually the exception rather than the rule. 

In order to obtain dependable data of real therapeu- 
tic value, and this is the only excuse for making use 
of the clinical laboratory in diagnosis, it is essential 
that not only the qualitative examination, but a thor- 
ough quantitative analysis of the mixed urine passed 
during a full twenty-four-hour period be carefully made. 

The collection of the specimen should be a matter 
for careful attention, and the patient should be led to 
understand the importance of this and told that all the 
urine should be collected according to the specific in- 
structions given, preserved with a preservative given 
them at the time the specimen is requested and the 
whole amount carefully measured in order that accu- 
rate information may be forthcoming. Too much em- 



154 Essays on Laboratory Diagnosis 

phasis cannot be laid upon this, to the physician as well 
as to the patient, for unless this is done the importance 
of the examination diminishes very materially. 

As a general rule, the whole twenty-four-hour collec- 
tion is best, although in some cases it may be desirable 
to separate the day urine from that passed at night. 
Again, it may be occasionally advisable, in addition to 
those aforementioned specimens, to have a freshly- 
voided specimen. 

To facilitate the proper collection of the specimen, 
personally I make use of a slip on which the following 
is printed. 

1. Empty the bladder at any stated time in the 
morning, say 7. A. M. This marks the beginning of 
the observation period, hence this water is not to be 
collected. 

2. Carefully collect in a two-quart jar or some sim 
ilar receptacle all the urine passed in the twenty-four 
hours from the starting time till the same time next 
day, taking care to empty the bladder exactly at the last- 
named hour. 

3. Measure the amount by means of the measuring 
slip and bring three or four ounces of the mixture 
labeled with your name and address and the amount 
passed and preserved with the tablet given for that pur- 
pose. Be sure the bottle and cork are absolutely clean. 

4. As soon as possible after the collection is com- 
pleted, deliver it to my office and notify me. (If nec- 
essary to send by mail, pack carefully in plenty of cot- 
ton and fully prepay the postage.) 



The Collection of the Urine 155 

5. Drink the usual amount of water. 

6. Call attention to any medicine which you may 
have been taking. 

In addition to this, I usually give the individual a 
handy little measuring slip which I devised some time 
ago for use with a standard two-quart Mason jar, with 
instructions to mark on the slip accompanying the spec- 
imen the approximate number of cubic centimeters of 
urine comprising the whole amount. This information, 
supplemented with the name and address of the patient, 
is pasted on the bottle. For a convenient container I 
suggest a three or four ounce medicine bottle thor- 
oughly cleaned and closed with a new cork if possible. 

Since urine readily decomposes, the specimen should 
be preserved in the vessel from the time of the first void- 
ing and kept covered and in a cool place. Any one of 
several preservatives may be used: Chloroform has 
evident advantage since it is found in every physician's 
office. It is not the best preservative, however, as some- 
times it will give a positive reaction with a copper so- 
lution, thus misleading the investigator as to the pres- 
ence or absence of sugar in the urine. This difficulty 
can usually be quickly overcome by first heating the 
urine and thus driving off any chloroform that may be 
in it before the sugar test is made. Ten or fifteen 
grains of powdered thymol is a very satisfactory pre- 
servative and offers a convenient way to keep the 
specimen in excellent condition. Toluol, one of the ben- 
zine series, is probably the best urinary preservative 
since its keeping qualities are marked and no mislead- 



156 Essays on Laboratory Diagnosis 

ing reactions are obtained because of its presence. 

Formaldehyde should not be used as a urinary pre- 
servative since it causes several important changes in 
the reactions which are obtained. The use of a piece 
of camphor gum is excellent, and provided none of the 
other preservatives can be easily obtained, this may be 
substituted. Boric acid (five grains to a three-ounce 
specimen) may also be used and has the advantage that 
a tablet may be given to the patient to place in the 
bottle in which the specimen is sent for examination. 
So far as I am aware, it has no deleterious effects upon 
the urinalysis. 

It is necessary to catheterize the ureters when the 
comparative capacity of each kidney is desired. This 
is also true when a bacteriologic examination of the 
urine previous to its passage through the bladder is 
required. Of course, it is unnecessary to note that both 
catheter and container should be absolutely sterile, and 
that after filling the container it should be quickly and 
properly stoppered and carried immediately to the lab- 
oratory for culture and such further examination as may 
be deemed advisable. 

In collecting a specimen of urine for bacteriologic 
examination for the cause of a cystitis and the possible 
manufacture of an autogenous-vaccine for the treatment 
of this condition, the following technic should be fol- 
lowed: Cleanse the surrounding parts thoroughly and, 
having previously boiled the catheter, which is best 
made of heavy glass, carefully pass it into the bladder, 
allowing a part of the urine to escape. Then uncork 



The Collection of the Urine 157 

the sterile test-tube, allow several Cc. to pass in and 
immediately recork. Finish the operation by washing 
out the bladder with a solution of boric acid or ordi- 
nary normal saline solution. The specimen is then 
treated by the bacteriologist according to the most ap- 
proved methods of procedure. 

In the differential diagnosis of certain local affec- 
tions of the urinary tract recourse is had to the collec- 
tion of several separate specimens of one voiding of 
urine. For information as to their value consult any 
work on genito-urinary disease. 



XVI. 
LOW TOTAL SOLIDS: ITS TREATMENT. 

Rep om 

THE GENERAL PRACTITIONER, 
East St. Louis, 111.. 

December, igio. 



CHAPTER XVI. 

LOW TOTAL SOLIDS: ITS TREATMENT. 

The conditions associated with a diminution in the 
amount of solids passed in the urine can hardly prop- 
erly be called a disease entity, but it will be found with 
surprising frequency by those physicians who take the 
trouble to make the complete urine examination a part 
of their routine examination. Of course, it is absolutely 
necessary, in order to find out the total solids, to be 
sure that the specimen examined is a part of the whole 
twenty-four-hour collection of urine. To do this it is 
important that the patient fully understands just how to 
make a proper collection. It is best to have a printed 
slip at hand, so that no mistakes can occur. In addi- 
tion to an information slip, I make it a practice to hand 
to the patient a measuring slip which I devised some 
years ago for simplifying the measurement of the spec- 
imen. The slip is so arranged that when it is pasted 
on a two-quart Mason jar it becomes a fairly accurate 
measuring instrument. 

It will not be the purpose here to go into details 
and endeavor to explain all of the conditions which are 
associated with a diminished elimination of the urinary 
solids, but it will be evident from what follows that the 
solid-index is a matter of very much more importance 
than many at present suppose. 

The normal secretion of urinary solids of the indi- 



162 Essays on Laboratory Diagnosis 

vidual living on the average mixed diet should be about 
50 grams in twenty-four hours. This figure can hardly 
be absolute, and there is considerable latitude in the 
factors which determine it. Variation, usually down- 
ward, depends in most cases upon the weight of the 
individual and the amount and kind of food that he is 
ingesting. Those living on a low proteid diet excrete 
considerably less solids than usual, there being an ap- 
preciable diminution in the total elimination of urea. 

In a series of several hundred— probably a thousand 
or more — analyses, it was remarkable what a large 
number of cases showed a low solid-index. The figures 
naturally varied greatly, and ranged from as low as 8 
grams in twenty-four hours to 172 grams (no sugar 
present in this case). From the figures obtained in 
my own work, I am safe in saying thar in 70 per cent 
of the pathologic non-diabetic urines the solids were 
lower than normal; in many of them the reduction 
ranging from 200 to 500 per cent, the average being 
about 20 to 25 grams. 

When the solids are decreased 30 per cent or more 
it is high time to make a careful search for the cause 
of this irregularity, and follow up the investigation with 
the best possible treatment. The greater the decrease, 
the more need for further and more exhaustive investi- 
gation. A really low solid-index is a serious sign, and 
deserves much more than the ordinary attention. 

Provided the possibility of definite organic disease 
is eliminated, there are a number of purely functional 
conditions which must not be overlooked. Principal 



Low Total Solids: Its Treatment 163 

among these is a decrease in the normal functions of 
the thyroid gland. It has been known for a number of 
years that the thyroid has a very important place in 
regulating the general metabolic activities of the system 
and investigation will show that there is a positive rela- 
tion between low solids and lack of the normal internal 
secretion of the thyroid. 

In such cases it is well to carefully look into the 
history, paying special attention to those factors which 
are known to be associated with the thyroid function. 
The neck should be carefully examined and measured. 
Many times goiter will be found, or, again, a condition 
of thyroid atrophy. This condition seems to be much 
more common in women. For its treatment the follow- 
ing prescription has been found to be of value: 

Ex. Thyroid Sice. ... gr. ss 

Aloini . . . gr. 1-25 

Calc. Lactatis . . . . . gr. x 
M. ft. Chart No. 1. 

Sig: One powder three times a day. 

Attention is called to the small dose of thyroid ex- 
tract. Some have said that such a small dose would 
be ineffective, simply because the text-books state that 
the proper dose is from four to five grains. My friend, 
Dr. Gordon G. Burdick, tells me that the dose of thy- 
roid extract usually given is absurdly high and often 
harm is done by such liberal dosage. At all events, 
looking at this formula from the standpoint of actual 
results achieved by its use, as shown by the laboratory 



164 Essays on Laboratory Diagnosis 

examinations, its use is of considerable efficacy in in- 
creasing the solid-index. It is admitted that there is a 
fine flavor of empiricism in this formula, but if used 
in those cases in which the thyroid is deficient and as a 
result the solids are markedly diminished and there is 
no organic disease, its administration will prove an en- 
couraging surprise. The calcium lactate supplies the 
calcium content of the blood, which is often depleted 
in these cases, and the addition of aloin serves to make 
the remedy a slight stimulant to the intestinal muscula- 
ture, and this is always of advantage. 

It is hardly necessary to add that frequent examina- 
tions of the urine are essential in carrying out this 
treatment, since in this way alone is is possible to detect 
the changes that are being wrought in the metabolism. 
It must be remembered that in practically all wast- 
ing diseases, especially in the cachexias, the aver- 
age elimination of solids is materially lessened. Or- 
ganic liver changes and nephritis are the principal or- 
ganic changes which have for one of their manifesta- 
tions a lowered urinary solid-index. In such cases it 
is manifestly difficult to obtain satisfactory lasting re- 
sults, but treatment along general lines often shows its 
influence upon the factor under consideration. 

The part played by the nervous states that are classed 
as "functional neuroses" in decreasing the solids has 
been known for many years. Hysteria and neurasthe- 
nia are the two most commonly met. The treatment is 
no different than in any other combination of circum- 
stances. 



Low Total Solids: Its Treatment 165 

Frequently the amount of phosphates is diminished 
out of proportion to the other urinary solids ; and when 
this is the case it is an evidence of a disturbance in 
the normal "nervous metabolism/' if such a term can 
be coined. Cases have been seen in which the phos- 
phates were almost absent. In such cases the nervous 
trouble must be found and its cause removed as far as 
possible, and the administration of phosphorus, eggs 
and, when it seems advisable, tonics, will cause a con- 
siderable change in the next specimen. 

Sometimes it is impossible to give a definite reason 
for the low solid-index, and when this is true the cause 
is general. The metabolism as a whole is disorganized. 
Rest and the removal of any disturbing elements, to- 
gether with attention to the emunctories and general 
tonic treatment, will accomplish wonders. In these 
cases sodium succinate (five grains three or four times 
a day) will be found serviceable. There is no drink 
like buttermilk; in fact, the free use of buttermilk alone 
is a valuable therapeutic procedure. Two or even three 
quarts may be taken daily; preferably some time after 
meals. 

When there seems to be a disturbance of the he- 
patic functions the use of boldine often has a beneficial 
effect, increasing the amount of solids passed in addition 
to the volume of fluid secreted by the kidneys. 

So far as general clinical experience is concerned, 
it will be found that if the solid-index is estimated and 
its variations appreciated, that the other therapeutic 
measures that may be indicated will have far more effect 



166 Essays on Laboratory Diagnosis 

and the sufferer's road to health will be much straighter 
and easier. 



XVII. 
WHAT THE URINE REPORT MEANS. 

Reprinted from 

THE AMERICAN JOURNAL OF CLINICAL MEDICINE, 

Chicago, 

August, 1909. 



CHAPTER XVII. 

WHAT THE URINE REPORT MEANS. 

Probably 90 per cent of the medical men in this 
country manage to get along some way or other without 
making a urine examination — or at least a complete 
examination. This certainly is an unfortunate state of 
affairs, as it must surely not infrequently result in grave 
mistakes; for without this most important information 
the therapeutist altogether too often gropes in the dark. 
True, many practitioners do profess to examine their 
patients' urine, but unfortunately this is usually a crude 
procedure and consists, in most instances, merely in de- 
termining the specific gravity, a test for albumin by 
boiling or the addition of nitric acid, and possibly a 
rough application of the Fehling test for sugar. More 
than this is rarely undertaken, and as a result of this 
many valuable therapeutic pointers are missed. 

The quantitative estimation of the substances nor- 
mally excreted through the urinary channel furnishes 
information regarding the actual metabolic activities 
of the body that necessarily must prove of immense 
value in the diagnosis of the conditions present in the 
majority of those individuals consulting the physician. 

The examination of the urine simply for abnormal 
elements alone would assist, it is true, in the diagnosis, 
provided certain definite lesions are present. However, 
the frequency of these pathologic conditions is not to 



170 Essays on Laboratory Diagnosis 

be compared with that of the deranged metabolic states, 
which unfortunately are so extremely common. For in- 
stance the mere positive test for albumin may or may 
not be of value. Thus in many individuals suffering 
from serious renal lesions albumin is not present at all; 
on the other hand, in a large number of cases the proof 
of the presence of the albumin may be positive and yet 
lead to an erroneous conclusion, for the patient may 
be suffering merely from some temporary irritation of 
the kidneys or possibly the so-called "alimentary albu- 
minuria." 

Those laboratory facts which tell us of the exact 
extent of the work of the body and give an insight 
into its metabolic processes are especially valuable when 
one is dealing with those chronic conditions that do not 
prevent the patient from continuing his usual vocation, 
as it is particularly in such conditions where a thorough 
knowledge of the metabolic and eliminative capacities 
of the patient is of such value. It is but rarely that 
this information is sought after in the routine work 
of the physician. 

Even in these days of enlightenment some physi- 
cians still believe that the examination of the urine is 
called for only in cases of suspected renal disturbance. 
Of course, the advantage of the urine test in such cases 
is self-evident, but this sporadic testing bears absolutely 
no comparison to the regular application of systematic 
urinalyses affording definite information regarding con- 
ditions that possibly may be the unsuspected cause of 
the more serious and maybe incurable organic lesions. 



What the Urine Report Means 171 

I do not believe that I am overstating matters when 
I say that every case of chronic disease should have not 
only one, but repeated urine examinations. Were this 
sufficiently appreciated by! (the average physician he 
would far more frequently insist upon this as an aid 
in making his diagnosis ; so, also, were the public rightly 
informed and thus prepared to appreciate this fact, they 
would be less loth to part with the small fee involved. 
At all events, all the advantages to be obtained from a 
complete examination of the urine can scarcely be enu- 
merated in the limited space of this article. 

The doctor adopting the positive rule to make a 
complete urinalysis in every case often will be in a posi- 
tion to discover conditions which otherwise might have 
been entirely overlooked, and which, when treated im- 
mediately, are distinctly amenable to appropriate thera- 
peutic measures. The information thus gained will ex- 
pose the real conditions and make it possible to insti- 
tute intelligent and successful treatment. 

To the clinician it is a matter of the highest import- 
ance not alone to be able to comprehend and thor- 
oughly to grasp the findings of the analytical report, 
but much more to read "between the lines" and gain 
an insight, as it were, into the actual condition of his 
patient. In order to assist in this, and further that the 
more salient features so frequently found in urine exam- 
inations may be better appreciated, a few important 
suggestions may not be out of place. Naturally, this 
can only be a condensed presentation of facts already 
found printed either in the text-books or current medical 



172 Essays on Laboratory Diagnosis 

literature. Very little is claimed to be original. 

The first important thing to do previous to making 
an examination of the urine is to insist that a complete 
and accurate twenty-four-hour specimen be secured. 
This is imperative, as it is well known that individual 
voidings of urine vary greatly from day to day, and 
so all careful quantitative work must be done y?ith a 
part of a twenty-four-hour mixture and the resultant 
figures calculated on the standard average twenty-four- 
hour basis. 

The amount of urine passed in twenty-four-hour pe- 
riods varies, of course, depending upon a variety of 
factors, but under ordinary circumstances it should be 
between 1,000 and 1,200 Cc. Under these circumstances 
the urine usually is of a light amber color, with prac- 
tically no deposit, and has a specific gravity averaging 
from 1,015 to 1,020. When the urine is dark in color 
and the amount is less than one liter, this is clearly an 
indication for increased consumption of water. This 
one point might well be read over several times, as it 
is a fact that the majority of people drink far too little 
pure water and consequently suffer from conditions 
caused by a highly concentrated urine. 

From the relative proportions between the specific 
gravity and the amount of urine passed in twenty-four 
hours it is possible to calculate with considerable accu- 
racy the amount of solids passed each day; and these 
figures are another important factor that should always 
be carefully noted. Multiply the last two figures of the 
specific gravity by Haser's coefficient — 2.33 — and the 



Wftat the Urine Report Means 173 

resulting figure is the approximate amount of solids in 
grams per 1,000 Cc. Many diseased conditions are de- 
pendent to a greater or less extent on a decrease of the 
urinary solids, with a consequent toxemia from the re- 
tained waste products. Also an increase in the solids 
is of considerable diagnostic value. 

Under this head are found a number of very nec- 
essary tests, several of which are simply qualitative, ap- 
plied to determine the presence or absence of certain 
pathologic elements, among which may be mentioned 
sugar, albumin, bile, blood, diacetic acid, acetone and 
indolacetic acid. 

Sugar and Albumin. — It is customary, if sugar or 
albumin is present, to estimate the amount either in 
grams per liter or grains per ounce. The albumin-con- 
tent may also be expressed in two ways, i. e., either in 
volume-per cent in twenty-four hours (as estimated by 
Purdy's centrifuge method) or in grams per cubic cen- 
timeter (or per 100 Cc), as easily and quickly esti- 
mated with my albuminometer, employing Goodman's 
phosphotungstic-acid solution as the reagent. 

Reaction. — The reaction of the urine is of consid- 
erable importance. Unless alkaline fermentation has 
taken place, the urine usually is acid in reaction, and 
the degree of this acidity should in every case be esti- 
mated, as it offers information of extreme value if one 
desires results. For convenience the urinary acidity 
is expressed in degrees of per cent, each degree repre- 
senting the amount of decinormal sodium-hydrate solu- 
tion required exactly to neutralize 100 cubic centimeters 



174 Essays on Laboratory Diagnosis 

of the total amount of urine. The normal acidity of 
the urine passed in the twenty-four-hour period varies 
from 30 degrees to 35 or 40 degrees. 

Another important factor to be calculated is the re- 
lation between the urinary acidity and the amount of 
urine passed in twenty-four hours. This has been made 
possible by the establishment of an "acid-index/' or 
"acid unit." According to Dr. A. L. Benedict, of Buf- 
falo, an "acid-unit" means 1 Cc. of urine with an acidity 
of 1 degree, or, in other words, the figure obtained by 
exactly neutralizing one cubic centimeter of urine with 
1 Cc. of 1-10 normal solution of NaOH, representing 
100 units. This acid-unit index is easily obtained by 
multiplying the degree of acidity by the amount of urine 
passed in twenty-four hours. Dr Benedict believes that 
the normal should be in the -neighborhood of 40,000 acid- 
units. According to a large number of tests, this is 
correct, representing about 1,000 to 1,300 cubic centime- 
ters of urine with an acidity varying from 30 degrees to 
40 degrees. 

In some cases the reaction will be alkaline, due either 
to fermentation of the urine in the bladder from cys- 
titis, to retention because of obstruction of the urinary 
outlet, or to fermentation after the urine has been 
voided. Usually alkaline urines are associated with 
the microscopic findings of pus-cells, an excess of epi- 
thelial debris, and the crystals of ammonia-magnesium 
phosphate, which show that the irritation of the lining 
of the urinary tract has been sufficient to draw many 
leukocytes there, that the epithelium has been exfoliated 



What the Urine Report Means 175 

much more than usual, and also that ammoniacal decom- 
position has taken place. 

Uric Acid. — At one time the estimation of uric acid 
was considered of great clinical import, but in spite of 
considerable work along this line and a large amount 
of literature upon the subject, it seems that the real 
clinical significance of this test as a routine measure 
is becoming less and less valuable. Its presence or ab- 
sence as determined by the qualitative test usually suf- 
fices. Then the microcsopic search for urates and uric- 
acid crystals generally precludes the necessity for mak- 
ing the tedious volumetric analysis for this substance. 

Urea. — The urea-index is one of the most necessary 
and important findings in the examination of urine. It 
is a valuable guide to the eliminative powers of the 
body, and, when rightly interpreted, is of great service 
to the diagnostician. Many urinary findings, such as 
high acidity, indicanuria and other evidences of auto- 
intoxication, very frequently are associated with a dim- 
inution in the amount of urea eliminated. It is for this 
reason that the urea-index is of such importance, as it 
must be evident that if the normal amount of nitrogen- 
ous waste products is not passed from the body from 
day to day, that serious metabolic disturbances are pres- 
ent. On the other hand, in diabetes and other condi- 
tions, the urea-index often is increased, and this, too, 
is just as valuable a guide to the physician. 

The normal urea elimination for the average indi- 
vidual is said by most authorities to be about 30 to 35 
grams daily. I have found it nearer 25 to 30 grams, 



176 Essays on Laboratory Diagnosis 

It is increased, however, by excessive use of meat and 
other nitrogenous foods, and by severe exercise. Some 
investigators have claimed that it is also increased in 
febrile conditions, but this finding is not always con- 
stant, as it has not infrequently been found diminished. 

Considerable stress has been laid upon the estima- 
tion of the urea-index of the urine of children, and the 
average normal elimination should be remembered. 
This is about as follows: Children from three to six 
years old, 1 gram per kilo.; from eight to eleven, 0.7 
gram per kilo., and from thirteen to sixteen, .03 to 0.5 
gram per kilo. 

Ammonia. — The estimation of the amount of ammo- 
nia present in the urine plays an important part in the 
determination of the actual conditions present regarding 
nitrogen metabolism. In severe metabolic disturbances 
usually due to toxemia, either as a result of the abnor- 
mal acid substances found in acidemia or as an effect 
of other as yet unknown factors, the urea-index is con- 
siderably diminished and in its place the ammonia passed 
in the urine is greatly increased. This is in all prob- 
ability due to the fact that the hyperacidity of the tis- 
sues and the blood stream in these cases calls for neu- 
tralization — as thoroughly and quickly as possible. This 
is probably accomplished in the liver by the neutraliza- 
tion of these acids with urea-precursors, probably am- 
monium carbonate, the urea being consequently de- 
creased and the ammonia increased. The evidence given 
by the estimation of ammonia in acid intoxication is 
worthy of far greater consideration. 



What the Urine Report Means 177 

Chlorides. — Since the chlorides of the urine are de- 
rived almost entirely from the chlorides ingested in the 
food, and as this is a very indefinite factor, it would 
seem that an accurate estimation of the amount of sodi- 
um chloride in the urine would not be of much clinical 
value, although, of course, decidedly of interest in ex 
perimental and research work. Since the chloride elim- 
ination is subject to such wide variations in health, in 
my own practice I find that an accurate estimation is not 
needed. After all, the quantitative test for chlorides 
does not give very definite signs so far as treat- 
ment is concerned, although the diminution of the sup- 
posed average normal figure is of interest and the 
entire absence of chlorides is a matter which should be 
taken into consideration, as it is always indicative of 
grave conditions, being practically always associated 
with certain acute febrile diseases, such as pneumonia, 
for instance. 

This approximate examination for chlorides may be 
easily accomplished and the tedious work of carrying 
out Volhard's estimation made superfluous. In cases of 
pneumonia, where the chloride-index is undoubtedly of 
great importance, it may be advisable to make a quanti- 
tative examination; but of course this, too, is useless 
unless it is made from a specimen from a 24-hour pass- 
age of urine, and daily. Unfortunately this is rarely 
done, as the physician usually has his hands full with 
other things to attend to in the treatment of such cases. 

Phosphates. — Another normal product eliminated 
in the urine is the phosphates. Much has been written 



178 Essays on Laboratory Diagnosis 

about their significance, but little definite diagnostic in- 
formation can be obtained from their estimation alone. 
Some writers have emphasized the fact that the phos- 
phates are greatly diminished in serious cases of 
nephritis ; but this is true of all the salts, and this infor- 
mation can be obtained from a study of elimination 
under the head of total solids. 

Bile. — The test for bile should be made in every 
routine analysis, as information regarding its presence 
or absence is of sufficient clinical help to be sought in 
every case. Many obscure conditions are associated with 
a stoppage of the bile-passages, and the positive test 
for bile in the urine is thus made an important point. 

Indican. — One of the more recent and at the same 
time most important urinary tests is the test for indican, 
which has been shown to be a product of proteid putre- 
faction in the body associated in the large majority of 
cases with intestinal fermentation and putrefaction. The 
accurate estimation of this substance is an exceedingly 
difficult matter, but means are at hand for approximate 
work which is of just as great practical value. Indican 
in appreciable traces, as shown by present methods of 
examination, is not normally present in the urine, and 
the degree of blueness caused by the indigo, which is 
oxidized during the test, is quite a positive index of the 
conditions present in the bowel. 

IndoL — Another product of intestinal putrefaction is 
indol, a body closely associated with indican and which 
is often eliminated in the urine in the form of indol- 
acetic acid. When this substance is present in appre- 



What the Urine Report Means 179 

ciable quantities it can easily be detected, and the report 
of its presence is a finding which gives us definite 
grounds for treatment. 

The test for indolacetic acid as devised by Herter 
of New York is a valuable one. It is simplicity itself 
and should always be made. If during the test for in- 
dican a drop of a 1 per cent, solution of potassium 
nitrite is added to the urine and an equal amount of 
HC1, a pink color is formed which varies in intensity 
with the amount of indolacetic acid present. The in- 
dican test may be finished as soon as this color has been 
noted, or not, as the case may be. 

The relation between the ethereal, or conjugate, sul- 
phates and the other solids in the urine may, in time, 
become an important factor. A considerable amount of 
work has been done along this line in France, but at 
present the difficulty of performing accurate work in a 
reasonable time prevents this from being done in routine 
analysis, although quite possible in research work. 

Blood. — The chemical test for blood in the urine 
usually is made only as a confirmatory test when the 
microscopic findings would lead to the belief that there 
is blood in the urine, when the urine is very highly col- 
ored, and when certain clinical facts are noticed which 
make it advisable to perform this test. The test for 
occult blood in the urine is very accurate and by its 
use it is often possible to detect the presence of blood 
when the microscope shows absolutely nothing sus- 
picious. 

Most textbooks make no mention of Meyer's phenol- 



180 Essays on Laboratory Diagnosis 

phthalein reaction, and as it is altogether the best test 
in every sense I give it here: Prepare the test solution 
by heating 4 grams of phenolphthalein, 20 grams of 
potassium hydrate, about 15 grams of zinc dust and 
200 c.c. of water. The heating should be prolonged till 
the pink color of the mixture is discharged. Then filter 
and bottle. The test consists simply of adding a few 
drops of this reagent to a few c.c. of urine and then 
adding one drop of peroxide. A pink coloration is in 
dicative of the presence of blood. 

Acetone. — The examination for acetone and diacetic 
acid ought always to be made in cases in which sugar 
is found in the urine or there is any suspicion of dia- 
betes. It has been stated that the examination for these 
substances is of more clinical importance than the esti- 
mation of sugar, as it is not simply the elimination of 
sugar that is fatal in cases of diabetes, but the excess 
of these acids and their precursors in the blood-stream, 
that causes acidosis and the toxic symptoms noticed 
previous to coma. 

Ehrlich's Diazo Reaction. — The diazo reaction of 
Ehrlich is still considered to be of some value in the 
differential diagnosis of several diseases. In the routine 
urine examination it is usually omitted, being carried 
out only in special cases. The conclusions of Ehrlich. 
which seem to be quite satisfactory in spite of some op- 
position in a number of papers published, are as fol- 
lows: This reaction is usually found in typhoid fever 
from the fourth or fifth day, and whenever this reaction 
is not present the diagnosis is considered doubtful. 



What the Urine Report Means 181 

Those cases which are undoubtedly typhoid fever and in 
which this reaction is faint or only found temporarily are 
usually mild and the prognosis favorable. In pulmonary 
tuberculosis this reaction gives a bad prognosis. 

The diazo reaction is sometimes, but not very fre- 
quently, found in measles, scarlet fever, erysipelas, 
miliary tuberculosis and septicemia. 

Xo urine examination is complete without a thor- 
ough examination of the sediment under the microscope. 
By carrying out this procedure in every case the pres- 
ence of certain chronic, insidious and dangerous condi 
tions is observed and information gained which it is 
impossible to obtain in any other way. 

Leukocytes. — The presence of an excess of leuko- 
cytes is evidence of some inflammatory condition in or 
near the urinary tract. (In specimens from women suf- 
fering from leucorrhea one frequently finds quite a 
number of pus-cells which are, of course, extraneous 
and should not be considered evidence of cystitis.) The 
presence of pus in the urine is very frequently asso- 
ciated with an increase in the number of epithelial celis 
found. The locality from which the majority seem to 
come is of diagnostic importance. When renal in origin, 
they indicate a marked irritation of the kidney ; from 
the bladder, they may evidence cystitis ; from the 
urethra, urethritis. It should be remembered that large 
numbers of labial epithelia are often found in speci- 
mens from women. 

Tube-Casts. — One of the most important urinary 
findings is tube-casts. It has been proven again and 



182 Essays on Laboratory Diagnosis 

again that the presence of casts in the urine is never 
noted in health. This finding is distinctly abnormal, 
although an impression seems to prevail in medical 
minds that casts in the urine inevitably are associated 
with Bright's disease in one or other of its forms. This 
is a mistake, as many abnormal conditions of the urine 
may serve to irritate the kidney-tubules to such an ex- 
tent that casts are formed, thrown off and seen in the 
urinary sediment. However, when casts are found and 
the urinary acidity as well as its concentration are ab- 
normal, this finding should enable the physician to pre- 
vent further damage to the kidney-substance by modify- 
ing the abnormal urinary conditions with suitable 
measures. 

The variety of casts found is of much diagnostic im- 
portance. Thus hyaline casts are very frequently found 
in hyperacid urines as well as in chronic interstitial 
nephritis; granular and blood casts are more often as- 
sociated with acute renal congestion or inflammation, 
while waxy and fatty casts occur in the amyloid, 
cirrhotic or contracted kidney and in the more chronic 
forms of nephritis. 

The presence of red blood-cells, spermatozoa, para- 
sites, etc., in the urine do not require to be referred to 
here, as these give evidence of findings which cannot 
easily be misconstrued. 

Of the unorganized elements usually found in the 
urine, the most important are crystals of the amorphous 
phosphates, calcium oxalate, urates, uric acid, triple 
phosphates and calcium carbonate. 



What the Urine Report Means 183 

Urates and Uric Acid. — The presence of an excess 
of urates and uric-acid crystals in the sediment of the 
urine is almost invariably associated with highly acid 
urine, although it has been conclusively shown that uric 
acid does not have any influence on the degree of acid- 
ity. The continued finding of these crystals points out 
a disturbed metabolism which has been called by some 
the "uric-acid diathesis" and which very often is asso- 
ciated with rheumatism or other so-called "rheumatic" 
affections. When these crystals are found in the urine, 
steps should be taken to prevent their persistence, as 
calculi very often are formed from them, causing much 
trouble. 

Oxalates. — Crystals of calcium oxalate are not in- 
frequently found in the urine, but do not yield any very 
definite clinical information. I have frequently found 
them in the urine passed soon after a person has eaten 
freely of rhubarb. Boston believes them to be common 
in the urine of persons that are overfed and of seden- 
tary habits and where there is much mental strain. 
Some investigators believe a persistent oxaluria may be 
a precursor of sugar in the urine. 

Triple Phosphates. — Crystals of ammonio-magne- 
sium phosphate, the most common form of which are 
the "coffin-lid crystals/' are frequently seen. Their pres- 
ence is evidence of ammoniacal fermentation of the 
urine, either in the bladder previous to micturation or 
after passage, if the urine is allowed to stand a long 
time unpreserved. 



184 Essays on Laboratory Diagnosis 

There are other and less important crystalline find- 
ings in the urine, but they will not be referred to here 
because of lack of space and their comparative un- 
importance. 



XVIII. 

THE THERAPEUTIC INDICATIONS OF THE 
URINALYSIS. 

Reprinted from 

THE AMERICAN JOURNAL OF CLINICAL MEDICINE, 

Chicago. 

October, 1909. 



CHAPTER XVIII. 

THE THERAPEUTIC INDICATIONS OF THE 
URINALYSIS. 

Possibly no one other procedure among the routine 
diagnostic measures carried out by the general prac- 
titioner gives quite so many and so varied indications 
for treatment as the urinary analysis. The urinalysis, 
properly made and rightly interpreted, can be of the 
greatest practical everyday usefulness to the practicing 
physician. 

No attempt will be made in this paper to touch other 
than the more important points in the routine examina- 
tion; nor will space be taken to outline treatment for 
diabetes mellitus, Bright's disease or cystitis. Aside 
from these important conditions, in which, of course, 
the urine examination is thoroughly , recognized as es- 
sential, there are many points of vital importance re- 
garding metabolism which are, unfortunately, usually 
overlooked. 

The complete urine examination should be made in 
the investigation of every case, and always from a part 
of a carefully collected 24-hour specimen. The exam- 
ination should include the quantitative estimation of the 
normal substances eliminated in the urine, and their re- 
lation one to the other, as well as the usual quantitative 
physical tests. 

The first and probably the most important quanti- 
tative test is for urea. Since urea is the principal nitro- 



188 Essays on Laboratory Diagnosis 

genous waste-product eliminated in the urine its fluctua- 
tions must necessarily be of importance. The normal 
urea elimination for a healthy individual should be about 
25 grams in twenty-four hours, or practically 2 per cent. 
Very frequently the urinalysis shows the urea-content 
from 25 to 50 per cent, and at times even 75 per cent be- 
low the average, and this is, to say the least, an import- 
ant point to the physician. It must be evident that if 
the urea is not being eliminated, some of its component 
elements are being stored up in the economy, to cause 
trouble later on; or, and this is more likely, abnormal 
acids in the blood unite with the urea-precursors, prob- 
ably in the liver, to form ammonia compounds. It has 
been stated that if the urea percentage is as low as 1.4 
per cent for several days in succession there is goo i 
reason to suspect definite renal damage. 

The successful treatment of individuals suffering 
from a diminished elimination of urea is no easy matter. 
The amount of water taken in must be increased materi- 
ally. An excessive amount of nitrogenous or proteid 
food should be eschewed, at least temporarily; and if 
an acidemic condition is present it must be controlled 
by the use of suitable remedies. 

Sometimes in cases showing a persistent low urea- 
index there is an associated disturbance of the thyroid 
function which could be carefully looked into with profit. 
The administration of suitable doses of thyroid extract 
has, in a number of cases, shown a marked change for 
the better. 

Frequently the liver is the principal seat of the 



The Indications of the Urinalysis 189 

trouble, the disturbance being due to the proverbial 
"sluggish liver.'' This, however, is not necessarily an 
indication for the ordinary so-called "hepatic stimulants." 

Boldine (an alkaloid obtained from peumus boldo), 
has a very beneficial effect upon these cases of dimin- 
ished metabolic activity. Given in doses of 1-60 to 1-30 
grain, or even more, four or five times a day, boldine 
seems to have a definite action upon the hepatic func- 
tions, and, while not increasing the bulk of urine 
passed, the solids, and in particular the urea, are con- 
siderably augmented. In addition to this, when possible, 
a course of physical exercise, either active or passive, 
should be prescribed. If convenient, the patient may be 
instructed to walk several miles each day. Breathing 
exercises, with a view to increasing the lung capacity, 
are also valuable. These, together with other physical 
measures, such as hydrotherapy, electrotherapy, etc., ma- 
terially increase oxidation in the body and assist in no 
small degree in accomplishing the desired end. 

Perhaps a few words might be said regarding the 
conditions associated with low total solids. The normal 
excretion of urinary solids should be from 50 to 60 
grams per diem, but there is considerable latitude in 
these figures, the variation — uually downward — depend- 
ing principally on the weight of the individual and the 
amount and kind of food he is taking, a diet low in 
nitrogenous elements causing an appreciable diminu- 
tion in the urinary solids. When the solids are de- 
creased 30 per cent or more, the conditions are serious 
and it is time to make a careful investigation and follow 



190 Essays on Laboratory Diagnosis 

this with the best treatment possible. While a contin- 
ued low specific gravity and diminished amount of urine 
may be entirely functional, very frequently it will be 
found that this is associated with organic renal disease. 
Provided this possibility can be eliminated, the treat- 
ment suggested for the increase of urea will also serve 
to increase the solids in general. 

A remedy which is undoubtedly an important factor 
in raising the amount of solids eliminated is sodium 
succinate. Five grains taken three or four times a day, 
alone or with boldine, often will render very effective 
service. 

The addition of buttermilk to the diet has also been 
found to be of value. 

An excessive degree of urinary acidity is another 
therapeutic indication which must not be overlooked, 
since it is an assured fact that many obscure and danger- 
ous conditions are at least associated with, if not actually 
due to, dealkalinization of the blood and its etiologic 
factors. The degree of acidity may be high (the normal 
varying from 30 to 40 degrees) and yet, owing to a 
decreased amount of water passed, there may be a com- 
paratively normal amount of acid units. (This figure 
is the relation between the degree of acidity and the 
twenty-four-hour amount of urine expressed in Cc, and 
should be about 40,000 in twenty-four hours.) 

When the degree of acidity alone is increased, the 
indication for treatment is evident — more water, thus 
diminishing the concentration of the urine and conse- 
quently its irritating qualities. Incidentally, it may be 



The Indications of the Urinalysis 191 

stated that no drug will offer better service in conditions 
of acidemia than plenty of pure water — distilled or car- 
bonated if so desired. If the acidity is high (the acid- 
units above 40,000 per diem), it should be reduced as 
carefully and speedily as possible, and dietetic sugges- 
tions given which will tend to prevent the further forma- 
tion of an excess of acids in the body. *The diet should 
t)e as free from meat as possible, and low in nitrogen. 
A free use of fruits, both fresh and cooked, as well as 
vegetables (preferably not dry legumes) and properly- 
cooked cereals is of value. The "lacto-farinaceous reg- 
imen" recommended by Combe is excellent. 

The medicinal treatment of this condition is as nec- 
essary as it is efficacious. The alkalies (sodium bicar- 
bonate, potassium or sodium citrate, magnesium carbo- 
nate, etc.) render excellent service. From 40 to 60 grains 
of sodium bicarbonate with plenty of water, alone or 
•combined with suitable eliminants and intestinal anti- 
septics and given from one to three times a day, as re- 
mote from meals as possible, may be administered until 
the acidity has been reduced to normal, the doses then 
being decreased materially and given less frequently, 
always keeping the degree of acidity at or slightly lower 
than normal. Two or three weeks of this treatment will 
give # eminently satisfactory results in the handling of 
many chronic conditions that are due to or associated 
with faulty metabolism and elimination, and which have 
previously resisted prolonged attempts of treatment by 
other less definite methods. When alkalies are indi- 
cated and contipation is present, magnesia may be sub- 



192 Essays on Laboratory Diagnosis 

stittited for sodium bicarbonate with even better results. 
If, on the contrary, diarrhea is present, lime water in 
liberal doses (6 to 8 ounces three to six times a day) will 
be found more satisfactory. 

Another salt which serves as an excellent urinary 
antacid and diuretic is potassium citrate. It is compara- 
tively pleasant to the taste and is not likely to cause 
gastric irritation ; 20 to 30 grains in water three or four 
times a day will usually be found sufficient. 

When the acidity of the urine is steadily lower than 
normal (a series of several urinalyses is always advis- 
able) and cystitis or other conditions producing ammoni- 
acal fermentation and decomposition of the urine are 
eliminated, the general metabolic activities will usually 
be found to be considerably below par and the thera- 
peutic suggestions made previously become of value. 
These cases very frequently show a marked decrease 
in the elimination of acid for several days, weeks, or 
even months, having a periodical "storm" or "crisis," at 
which time the urinary acidity is tremendous, the gen- 
eral condition of the patient is serious, and the condi- 
tions are as completely opposite to the previous findings 
as could well be imagined. 

The treatment of these cases is no easy matter, and 
it is a question whether alkalies should be given or not. 
At all events, no harm will be done by their judicious 
use under these circumstances, and, when combined with 
suitable elimination and stimulation, success will be as- 
sured. 

The treatment of those conditions associated with 



The Indications of the Urinalysis 193 

an excessive elimination of ammonia in the urine is prac- 
tically the same as that of acidemia, since, as has been 
mentioned before, the high ammonia-index is caused by 
the neutralization of urea-precursors by the excess of 
acids present in the body, thus substituting urea with 
ammonia compounds. The same is true when the so- 
called "acid bodies of diabetes" — acetone, diacetic acid 
and oxybutyric acid — are found. The vigorous use of 
alkalies will give help ; that is, at least temporarily. 

The indican and the indoxyl group remain to be 
considered. The detection of indican is a very simple 
matter, and although its importance per se still seems to 
be a matter for discussion, its presence, without a ques- 
tion, is a definite guide to equally definite treatment. 
Ninety-nine cases out of a hundred evidencing marked 
indicanuria have associated with them an intestinal dis- 
turbance of greater or less severity. It is, however, quite 
possible for serious trouble to be present, and yet no 
trace of indican be discovered in the urine ; but it is safe 
to say that whenever indican is found, eliminative and 
dietary treatment is distinctly indicated, and in direct 
proportion to the amount of intestinal putrefaction 
present. 

In addition to eliminants, of which there are a pro- 
fusion (calomel in small broken doses still holding its 
own, saline laxative following it closely, with phenol- 
phthalein and possibly agar-agar in certain cases), the 
use of intestinal antiseptics gives valuable assistance. 
The examination of the urine from an extensive series 
of cases in which sodium sulphocarbolate (5 to 15 grains, 



194 Essays on Laboratory Diagftosis 

three or four times a day) had been administered, 
showed a rapid and marked decrease in the fecal putrid 
ity and the accompanying urinary indican, with a corre- 
sponding favorable change in the usual unpleasant mani- 
festations associated with autotoxemia. 

Another therapeutic method which is now being ex- 
tensively advocated, and rightly so, is the introduction 
into the intestine, by the mouth, of cultures of the bar 
cillus of Mas sol — an organism which, in addition to 
producing an excess of lactic acid, seems to have a defi- 
nite inhibitory effect upon the putrefactive micro-organ- 
isms in the bowel. Much is being written on this sub- 
ject, and it seems evident that this is a therapeutic meas- 
ure that has come to stay. When the germs are ad- 
ministered in tablet form, care should be taken to use 
them very freely — merely one or two tablets every few 
hours is not enough. On the other hand, if the patient 
can use milk soured with these tablets, and likes it, this 
method is an excellent way to secure a large and flour- 
ishing growth of the "friendly germs" in the bowel. 

In the treatment of these conditions associated with 
indicanuria, elimination and intestinal antisepsis are ex- 
cellent, but they are not enough. The diet should be 
modified and strict injunctions given to the patient to 
avoid the hyperproteid diet. The dietary suggestions 
given previously are of value in these cases; in fact, 
the so-called "antitoxic diet" is a most excellent adjuvant 
measure in the treatment of a large number of the 
chronic diseases. 



XIX. 
LABORATORY HELP IN TUBERCULOSIS. 

Reprinted from 

THE AMERICAN JOURNAL OF CLINICAL MEDICINE, 

Chicago, 

July, 1009. 



CHAPTER XIX. 

LABORATORY HELP IN TUBERCULOSIS. 

Since the discovery of the tubercle bacillus by Koch 
and the simple methods of staining by Ziehl and Gab- 
bet's method, the examination of the sputum of sus- 
pected tuberculous cases has become a routine, and it 
is rare that a progressive practician attempts to treat 
a patient without having the laboratory report regard- 
ing the presence or absence of that bacillus. The stain- 
ing of the sputum smear has become an absolutely es- 
sential procedure, and it is not necessary to add that 
it is both advisable and imperative in the investigation 
of any patient showing one or more of the cardinal 
symptoms of pulmonary tuberculosis. In addition to 
this, however, there are other important phases of the 
work done in the laboratory which unfortunately usually 
are neglected by most physicians and which, more par- 
ticularly, I wish to refer to in this paper. 

It is well understood that tuberculosis, whether 
localized in the lungs, a joint, or some other part of 
the body, is not solely a local disease. Rather, it is 
always associated with other abnormal conditions of 
the body, especially of metabolism, and for this reason 
it is absolutely essential that the general practician 
should make general and repeated use of the facilities 
of the scientific laboratory in his routine investigation 
and treatment of cases of this kind. Thus, the exam- 
ination of the urine should be made early. Following 



198 Essays on Laboratory Diagnosis 

this a careful examination should be made regularly 
every third or fourth week. 

The first urinalysis will point out the general condi- 
tion of the patient's metabolism, while the succeeding 
ones will enable one to follow carefully the case, as only 
in this way can a proper idea of the metabolic activities 
of the body be gained and appreciated. The physician, 
by giving his close attention to the findings, will then 
be in a position to proceed in accordance with the find- 
iiigs in the report. 

The urinary examination should be complete and 
thorough and not be confined merely to the almost useless 
tests for albumin and sugar, which, though rarely re- 
sorted to, seem to be the customary scope of the aver- 
age "urine examination." The advantage of such lim- 
ited tests would be noted only in the few cases in which 
diabetes or Bright's disease were present ; and even then 
the precipitation of a copper solution does not necessa- 
rily positively indicate diabetes, nor does the finding of 
albumin definitely prove the existence of Bright's dis- 
ease. To be of real service, the examination should 
at least include quantitative estimations of the normal 
elements eliminated in the urine, the most important 
figures of which are the amount, the urea-index, the 
solids, and the degree of acidity. 

The examination of a number of specimens of urine 
from tuberculous individuals shows that the amount of 
urea eliminated is almost always diminished, and in the 
majority of cases seriously so. This being true, it is 
quite easy to understand that in addition to fighting the 



Laboratory Help in Tuberculosis 199 

localized infection, the patient has to contend with the 
disadvantages of a large amount of effete matter which 
is not being eliminated from his body in the proper 
amounts and which consequently either is circulating in 
the blood-stream or being stored up to produce trouble 
sooner or later. Dr. Foxhall, in an article recently pub- 
lished in The Lancet, states that if the average per- 
centge of urea excreted is below 1.4 per cent for ten or 
fifteen days it nearly always indicates definite renal dam- 
age — a condition which cannot be appreciated in time 
to render any service of value, unless the urine examina- 
tion has been a routine diagnostic procedure. 

Another very important finding in the urine exam- 
ination that has as yet not received the attention it de- 
serves is the estimation of its acidity. A number of in- 
vestigations have conclusively shown that an excessive 
degree of urinary acidity is a very important factor, 
since it is always associated with certain metabolic dis- 
turbances which have for their principal manifestation 
autointoxication, general malaise, indefinite aches and 
pains, a susceptibility to colds, and a general condition 
of lowered vitality. This higher urinary acidity probably 
is due to a condition of alkali-hunger, and evidenced by 
a marked systemic hyperacidity, or acidemia. 

We have as yet to learn the exact raison d'etre for 
this condition, nor do we know positively the exact com- 
position of the acid substances which may cause this 
abnormality, but it may be that they are in the same 
class with the products of proteid putrefaction, such as 
indican, which is an acid salt — potassium indoxyl-sul- 



200 Essays on Laboratory Diagnosis 

phonate. Indicanuria is frequently found associated 
with intestinal putrefaction, but may also be found in 
cases exhibiting proteid putrefaction, in other parts of 
the body, as for instance, empyema, large tuberculous 
lesions, etc. 

The examination of the urine for acidity should be 
carried out in the routine of every case. More particu- 
larly is this imperative in the investigation of those suf- 
fering from tuberculosis, for in addition to fighting the 
local infection, the diminished degree of alkalinity of 
the blood renders that fluid less resistant, diminishes its 
capacity to carry oxygen, and generally devitalizes the 
cells that are nourished by it. 

The employment of the litmus test is most unsatis- 
factory, and it should, therefore, be entirely discarded; 
neither is the examination for acidity of a single voiding 
of urine of much value, as the degree of urinary acidity 
varies greatly from time to time, depending upon the 
relation between the time of urination and alimenta- 
tion, and also whether the specimen is passed in the 
evening or in the morning. For this reason care should 
be taken to instruct the patient as to how to obtain a 
complete twenty-four-hour specimen of urine, and after 
the total quantity has been carefully noted a portion 
from the well-mixed fluid may be set aside for an early 
examination. Provided this is done, the normal degree 
of acidity should range between 30 and 40 degrees, and 
the number of acid-units (the relation between the de- 
gree of acidity and the amount of urine passed) should 
extent. 



Laboratory Help in Tuberculosis 201 

be about 40,000. This represents about 1,300 Cc, or 
urine with an acidity of 30 degrees, or 1,000 cubic centi- 
meters of urine with an acidity of 40 degrees. 

If the acidity proves to be very high — and this only 
too often is the case — it should be promptly reduced by 
the administration of suitable alkaline remedies. On the 
other hand, if the acidity is markedly diminished, the 
possibility of cystitis or other conditions usually asso- 
ciated with fermentation of the urine should be consid- 
ered; or, if these are not the cause of the low degree 
of acidity, then the emunctories should be thoroughly 
stimulated in order that the acid substances which evi- 
dently are being stored up in the body may be neutralized 
in the cells or allowed to be eliminated in the usual way. 
It has been found that if conditions showing a dimin- 
ished urinary acidity are allowed to persist for any 
length of time, it is quite frequently followed by cer- 
tain "crises" which are not only decidedly inconvenient 
to the patient, but often dangerous. 

A good deal more stress should be laid upon the find- 
ings in the feces than now is the case. One of the fre- 
quent occurrences associated with pulmonary tubercu- 
losis is tuberculosis of the intestine, or at least a mark- 
edly disturbed functional condition of this organ. An 
examination of the stools, in addition to showing the 
digestive capacity of the intestinal juices, and also the 
absorption by the villi, gives one a very good idea of the 
extent of the putrefactive changes which are usually 
present, as well as whether infection of the bowels by an 
abnormal bacterial flora is present, and if so, to what 
extent. 



202 Essays on Laboratory Diagnosis 

Unfortunately, the fecal analysis is but rarely made, 
except in large hospitals or institutions. Its routine use 
would be attended with more success in practice, as un- 
doubtedly the information gained by such examination 
would give pointers of distinct value in the treatment of 
the abnormal local conditions so frequently associated 
with tuberculosis. 

One of the most important things that is necessary 
for the physician to do in the home treatment of tuber- 
culosis is to give careful attention to the digestive appa- 
ratus, for the reason that one of the important factors 
in the treatment of tuberculosis seems to be the neces- 
sity for hyperalimentation. If the capacity of the stom 
ach to digest food is diminished or impaired, this mat- 
ter should be appreciated at the earliest possible moment 
in order that proper steps may be taken to remedy this 
condition. Stomach analysis offers a solution to many 
of these difficulties, and it is distinctly advised in every 
case of pulmonary tuberculosis associated with digest- 
ive disturbances, provided, of course, there is not se- 
vere asthenia and any of the few conditions which neces- 
sarily contraindicate the employment of the stomach- 
tube. 

The examination, of the urine always, and of the 
feces and gastric contents when necessary, together, of 
course, with the frequent bacteriologic examination of 
the sputum, will do much to enable the physician to 
practice better medicine in general and to obtain better 
and more satisfactory results in the treatment of this 
disease in particular. 



XX. 

THE URINE IN TUBERCULOSIS. 

Reprinted from 

THE MEDICAL STANDARD, 
Chicago, 

April, 19 10. 



CHAPTER XX. 

THE URINE IN TUBERCULOSIS. 

In the treatment of tuberculosis we have a great 
and by no means easy problem to handle, and because of 
this we need every resource that science can afford or 
that research can secure. Among many procedures 
there is one — the examination of the urine — which will 
give us help that may lead to a more successful out- 
come of our efforts, and for this reason it should, I 
firmly believe, be given much more credence and atten- 
tion. 

It is generally understood that tuberculosis is not 
simply a condition in which some part of the body has 
been invaded by the tubercle germ, but rather that it is 
a general condition of lowered resistance with the addi- 
tion of a localized focus of infection. It will be found 
on careful investigation that practically every tubercu- 
lous individual shows a marked depravity in the meta- 
bolic activities of their bodies. 

Since the metabolism plays such an important part 
in both disease prevention and cure, it would seem that 
a knowledge of just how well these processes were be- 
ing carried on and to what extent deficiencies or dis- 
turbed relations are present, might be of much assist- 
ance to the physician that may be directing the fight 
against this widespread and terrible disease. 

Physiological chemists, by their studies of the inner 



206 Essays on Laboratory Diagnosis 

workings of the body, have demonstrated that the true 
urine shows, as does no other analyzable body fluid or 
secretion, the true state of the metabolic equilibrium. 
In addition to giving information regarding the func- 
tion of the kidneys and the conditions present in the 
whole length of the urinary tract, the constituents of the 
urine and their relations to one another and to the nor- 
mal, are as perfect a mirror of the cellular activities of 
the body as we can hope to find. 

This being the case, it must be plain that in tubercu- 
losis, as in all other perverted states, i. e. y in all general 
disease processes, the examination of the urine is not 
only a valuable adjunct, but an essential. 

Unfortunately, there is still a wide variance of opin- 
ion on this subject, and by no means all are in accord 
with the above statements; but the fact, however, re- 
mains. The more study that is given to this subject, 
the more definitely will it appeal to the student as be- 
ing both right and proper. A careful investigation of a 
number of tuberculous individuals will quickly con- 
vince the skeptic and encourage the doubting. 

It is admitted that there are several other clinical 
laboratory procedures that are now well engrained in 
the medical constitutions of the progressive physicians. 
Principal among these are the various tuberculin reac- 
tions, of which the Moro or von Pirquet tests are 
probably the best, and the examination of the sputum 
for tubercle bacilli. The opsonic index may or may not 
be of value; one thing is certain, no matter whether it 
can be invariably accurately made or not, that it is a 



The Urine in Tuberculosis 207 

physical impossibility for the general practitioner to 
make this test, and for this reason it must be ruled out, 
at least for the present. 

The urine examination, on the other hand, is easily 
and accurately made by any man that is willing to de- 
vote as little as ten or fifteen minutes of his time to 
this work. The equipment needed is comparatively 
slight, and with a little experience any physician can 
make a very creditable and extremely valuable analysis. 
Just what the varied findings mean is not as fully ap- 
preciated as might be, and because of this there is still 
a lack of interest in this subject. However, it is to be 
hoped that during the next few years a wide and ever- 
increasing interest will be aroused, and that, as a conse- 
quence, much more light will be thrown on this and 
allied subjects. 

One of the disorders most frequently encountered 
is a diminution in the normal amount of urinary solids 
passed in tweny-four hours; of these, of course, urea 
is the most important. Just why this should be so is 
still a matter of conjecture, although several very plaus- 
ible reasons have been advanced. At all events this con- 
dition is not necessarily a sign of definite kidney change, 
as has been stated by some. 

The diminution in the amount of urea excreted may 
be due to a decrease in the normal blood alkalinity, the 
urea-precursors being used up and eliminated as am- 
monia compounds. Again, the generally lowered vital 
state may serve to prevent the elimination of the nitrog- 
enous waste already present with a resulting increase 



208 Essays on Laboratory Diagnosis 

in the toxicity of the blood and the body fluids. As a 
matter of precaution, it must be remembered that since 
the urea-index is an excellent guide to the proteid me- 
tabolism, the figures obtained will receive their proper 
value only when a general idea is gained of the amount 
of nitrogenous food ingested. For this reason, in the 
tuberculous state the usually decreased urea-index is in 
some cases often masked by the tremendous excess of 
urea resulting from the forced feeding of eggs and milk 
which is still altogether too commonly used. It might 
be added that if the urea-index is above 3 per cent, or, 
say, 30 grams, in twenty-four hours, that the indication 
is to diminish the proteid ration. 

The results of a number of urinalyses made in the 
early tuberculosis state show that when the ordinary 
diet is taken, the urea is diminished usually from 75 to 
200 per cent, averaging, perhaps, one-half the normal. 

The calcium content of the urine of tuberculous pa- 
tients is practically always increased. Senator, the fa- 
mous German clinician, having proved this over thirty 
years ago. This is an interesting fact, and it is unfor- 
tunate that the procedure necessary to determine this 
factor is so tedious and complicated, for were it reason- 
ably simple we might find in the calcium-index a guide 
to the proper administration of calcium wherewith to 
balance this excessive loss. 

On the other hand, it has been found that the elim- 
ination of phosphates is considerably below the normal, 
and it has been suggested that this may be due to a dis- 
turbance in the metabolic equilibrium presided over 



The Urine in Tuberculosis 209 

directly by the nervous system; in other words, a nerv 
ous disorder. Dr. J. Henry Dowd, of Buffalo, has 
done some interesting and original work along this 
line, and concludes that the phosphatic index is of ex- 
treme importance, serving to point out serious meta- 
bolic faults in their earliest beginnings. 

The estimation of the urinary acidity in the tuber- 
culous is a matter that will give the investigator much 
food for thought. It is believed that a study of this 
subject alone, with its relation to blood alkalinity and 
the various associated conditions, will prove of immense 
value in forwarding the combat now being waged 
against tuberculosis. It is still supposed by some tlist 
this test is of little or no value, but in spite of this it has 
been found of inestimable service, and I have no hesita- 
tion whatever in stating that this procedure should be 
carried out in the routine of every urine examination. 
It has been conclusively shown that an excessive de- 
gree of urinary acidity is a very important factor, since 
it is always associated with certain metabolic errors 
which have for their principal manifestations autoin- 
toxication, general malaise, indefinite aches and pains, 
a susceptibility to colds and various infections, and 
a general condition of lowered vitality. This highel 
urinary acidity is probably due to a condition of alkali- 
hunger, and evidenced by a marked systemic hyper- 
acidity or acidemia. 

This test will be found to be particularly useful in 
tuberculosis, as a check on the alkalinity of the blood 
is of importance, for upon this factor depends the ca- 



210 Essays on Laboratory Diagnosis 

pacity of the phagocytes to carry on their fight, and if 
there is an excess of acid-substances in the blood, that 
fluid must of necessity be much less resistant to disease, 
owing to its diminished capacity to carry oxygen. The 
inevitably decreased interchange of gases and the con- 
sequent loss of vitality of every microscopic cell-struct- 
ure is of prime importance and a matter that should not 
be overlooked. 

It must be remembered that there are several ex- 
traneous factors, such as cystitis or retention of urine, 
or, for that matter, any circumstance which tends to 
promote alkaline fermentation, which will materially 
modify the findings, and for this reason should be reck- 
oned with, and, if possible, guarded against. 

Another abnormal finding frequently seen in the 
urine of the tuberculous is indican. The test for indi* 
can is an important one and should be made in each 
urinalysis, preferably quantitatively. Personally, I am 
willing to commit myself by unqualifiedly saying that 
indican in more than the merest trace is evidence of 
a pathologic condition which requires attention. The 
contention of some that indican itself is non-toxic and 
that it is usually present in the urine of mfeat-eaters, 
does not alter the fact that the conditions associated 
with indicanuria are decidedly detrimental to those sup- 
posedly in the best of health, and, of course, doubly so 
to those burdened with the presence of an active tuber- 
culous lesion. 

Indicanuria is not only found associated with intes- 
tinal putrefaction, but may also be found in cases exhib- 



The Urine in Tuberculosis 211 

iting proteid putrefaction in other parts of the body, as, 
for instance, empyema, large tuberculous lesions, etc. 

Another substance closely allied with indican is in- 
dolacetic acid, and it might be well to make a test for 
this as a routine. It is a very easy procedure, consist- 
ing simply of acidulating a few cubic centimeters of 
urine with an equal volume of hydrochloric acid and 
adding one or two drops of a 1 per cent solution of 
potassium nitrite. A slight pink coloration is a positive 
test. 

Little needs to be said of the Diazo-reaction of Ehr- 
lich, as it is a procedure of comparatively slight value. 
Its disadvantages lie in the fact that it is not con- 
stantly found in any condition, and it may be found in 
several widely different diseases. It may be of some 
corroborative value in the diagnosis of suspected ty- 
phoid fever, and it is true that it is sometimes found 
in the acute miliary form of tuberculosis, but still its 
diagnostic value is decidedly limited. 

A French investigator has recently suggested that 
there may be certain definite substances passed in the 
urine of the tuberculous which prevent alkaline fermen- 
tation. He keeps specimens for several days or even 
weeks, testing the acidity from time to time. This is 
hardly a practical proposition in general practice. How- 
ever, it is quite possible that future investigators will 
find some urinary test which will be as definite and ac- 
curate as the tuberculin reaction, but as yet this is a 
task for the research man. 

The presence of albumin, bile, blood, pus and other 
pathologic elements should warrant the same attention 



212 Essays on Laboratory Diagnosis 

as though found in any other disease. Their signifi- 
cance is probably of no greater import in tuberculosis, 
pointing as they do to disturbances which require the 
same care as under other and different circumstances. 

In closing, it might be well to add that as a guide 
to the proper dietetic management of individuals suf- 
fering with tuberculosis the examination of the urine 
stands pre-eminent. The comparatively small amount 
of bother involved is more than balanced by the in- 
creased measure of success which results from careful 
and accurate work. The finding of an increased urea- 
index, an excess of chlorides or urates, indican and its 
congeners or an excessive degree of acidity are all 
points of importance, and, rightly appreciated, should 
serve as a stimulus to radical reforms in the diet and 
general hygiene. 



XXI. 

CONCLUSIVE RESEARCHES IN 
METABOLISM. 

(A paper read before the American Association for Clinical 
Research, Boston, September, 1910.) 

Reprinted from 

THE LANCET-CLINIC, 

Cincinnati, 

November 12th, 1910. 



CHAPTER XXL 

CONCLUSIVE RESEARCHES IN META- 
BOLISM. 

My interest in clinical research work ends just as 
soon as it gets beyond the possibilities of the capacity, 
time and facilities of the general practitioner. One of 
my great aims is, in my small way, to stimulate a greater 
interest amongst the rank and file of the profession in 
the simple laboratory work which is not only the most 
helpful in the routine of general practice, but absolutely 
essential to the proper investigation of every case com- 
ing to the physician for help. 

I want to impress upon the members of the Amer- 
ican Association of Clinical Research here assembled, 
that the several "Conclusive Researches in Metabolism" 
to which I shall briefly refer in this paper are none of 
them so tedious or complicated that they cannot be 
carried out by any physician anywhere. 

There is a mistaken idea that is unfortunately quite 
prevalent that the investigation of the chemical cell ex- 
changes of the body is only called for in the study of 
certain more or less defined disorders of metabolism. 
All too often the "research" consists in a few questions, 
a cursory examination and, once in a while, an "exam- 
ination of the urine" which really is nothing more than 
a farce and to all intents and purposes useless and a 
waste of time. I confess that this is a strong state- 
ment, but, nevertheless, you all can testify to its truth. 



f 
216 Essays on Laboratory Diagnosis 

Thousands of practicing physicians in this day of 
progress seem» to have a mistaken idea that research 
work is only for the research laboratory and entirely 
out of their reach. There could be no greater fallacy. 
One cannot too often reiterate, or too thoroughly im- 
press the fact that upon the much neglected factor of 
the metabolic cell exchanges carried on in the system 
hangs the inception and progress of a goodly share of 
all disease, as well as its prevention and ultimate cure. 

Upon what is the so-called vital resistance depend- 
ent if not upon the important changes ever going on 
in the millions of minute body cells? This being grant- 
ed, should not the study of the metabolism be made 
the most important part of the investigation of every 
individual consulting us, regardless of their several and 
widely different ailments ? 

By far the largest amount of information regarding 
the metabolic activities of the body may be learned from 
the careful urine examination. It is granted that other 
and more complicated procedures may be attempted, 
but these lead us beyond the confines of the work of the 
average physician, and for this very reason will not be 
mentioned here. I like to repeat as often as possible a 
more or less axiomatic statement: "There is no one 
diagnostic procedure which gives us so many and so 
varied therapeutic pointers as does the urinalysis. ,, I 
think that you will all agree with me that this is true. 

The most important urinary findings are not albu- 
men, sugar, casts, or any of the more common abnor- 
mal substances for which we have all been so thoroughly 



Conclusive Researches in Metabolism 217 

taught to look. These findings cannot give us nearly 
as much therapeutic information as several others of 
which I shall now speak — and this for the simple rea- 
son that they are usually evidences of definite organic 
disease conditions which, it is well known, are by no 
means easily handled. In other words, the abnormal 
urinary findings — albumen, sugar, casts, etc. — are re- 
minders that our study of the patient has been made 
rather late in the day. 

In my estimation, the most important urinary find- 
ings are those which cast a light on the inside workings 
of the human machine ; in other words, the quantitative 
estimations of the several normal wastes which are 
eliminated in the urine. Chief amongst these are the 
urinary acidity and the solids — urea, of course, being 
the most important one. 

As I have stated elsewhere, the urinary acidity is a 
factor of prime importance in the study of any disease 
condition; yet, in spite of this, its value to the clinician 
has been persistenly overlooked. It is still the excep- 
tion rather than the rule to estimate the degree of acid- 
ity in every case, and if, perchance, a test is really made, 
the old-fashioned litmus test is usually all that is at- 
tempted. 

No more conclusive evidence as to the proper car- 
rying out of normal metabolic functions, or not, as the 
case may be, can be learned than from this simple and 
easy test alone. Let us for a few mioments consider 
what the variations in the urinary acidity really mean. 
Eliminating the changes in the acidity due to extrane- 



218 Essays on Laboratory Diagnosis 

ous circumstances such as the retention of the urine, 
fermentation and its modification by drugs, we can read- 
ily understand that this factor must give us a definite 
idea of the alkalinity of the blood. As a matter of fact, 
the test for urinary acidity, because of its convenience 
and simplicity, supersedes absolutely the estimation of 
the alkalinity of the blood. 

I need hardly emphasize the immediate clinical im- 
portance of this factor in diagnosis, prognosis and treat- 
ment. You will recall that upon the presence of free 
alkali in the blood-plasma depends one of its most im 
portant functions, viz., oxygen-exchange. And what 
does not depend upon the oxygen-carrying capacity of 
the blood? Here we have a matter of such far-reach 
ing interest to every practitioner, no matter what may 
be his creed or specialty, that too much can hardly be 
said to stimulate more interest in its study. 

Not only should the foregoing be taken into con- 
sideration, but one may with much advantage consider 
more carefully the influence of hyperacid urine upon 
the kidneys and urinary tract. It is not difficult to im- 
agine that the irritating qualities of urine vary directly 
with its acidity. And this fact is demonstrated daily 
with unerring accuracy. Two years ago I found that 
many cases showing an excessively high acidity showed 
hyaline casts and other evidences of irritation. Now 
comes a prominent German investigator with the state- 
ment that all albuminurias should be discounted until the 
urinary acidity has been made normal in vivo. 

Much more might be said regarding the influence 



Conclusive Researches in Metabolism 219 

and importance of the urinary acidity; but this will, I 
hope, be worked out in the daily routine of every mem- 
ber present, and I can assure you that the work carries 
with it an intense interest and possibilities for results 
that cannot for one moment be gainsaid. 

Another urinary finding which is also of much value, 
but which, probably because of its importance, has been 
persistently overlooked, is the ammonia-index. Physio- 
logical chemistry explains to us the "why" of ammonia 
elimination, and without going into details, we believe 
that the ammonia-index is closely related to the acidity 
and serves to show us just how well the human econ- 
omy is handling the excess of acid substances which get 
into the blood stream. Why, may I ask, should am- 
monia estimations be so closely confined to the study of 
diabetic urines? Are there no other acid bodies in the 
blood save acetone and diacetic acid? Is not indlcan 
an acid body? And diacetic acid? And, for that mat- 
ter, several other unknown products of intestinal putre- 
faction ? 

One would suppose that the importance of the urin- 
ary solids would be considered more often than is the 
case. The evident importance of their quantitative esti- 
mation is appreciated by the majority, but one small 
factor practically puts a study of the solid-index, or, 
better still, the solid-indices, out of the question for most 
physicians. It necessitates the procuring of a full 
twenty-four-hour specimen, which in the majority of 
cases seems too difficult to explain, or too much trouble 
to cause the patient. Rightly speaking, no urinary test 



220 Essays on Laboratory Diagnosis 

should be made save from the full twenty-four-hour 
amount. Some will not fully agree with me; but when 
one is studying the metabolism none can deny that my 
contention is right. 

A urine examination without a quantitative urea 
test is not very much good. The variations in the urea- 
index alone are often sufficient to lead to a definite diag- 
nosis and effective treatment. The relation of the urea 
to the acidity and ammonia is very close; for it so hap- 
pens that the alkaline urea-precursors are, to a certain 
extent, used up in nature's attempt to maintain the blood 
alkalinity at normal. So we are justified in expecting 
that with a high acidity one will more often than not 
find high amm'onia and low urea. 

The other solids, most important among which are 
the chlorides and the phosphates, should also be con- 
sidered. Very frequently the chloride-index will ex- 
plain the reason for an intractable hyperchlorhydria ; 
and the reduction of this figure to normal will cure the 
trouble. It must be remembered that the chloride-index 
is a very indefinite factor simply because it varies so 
much with the intake of common salt. The elimination 
of phosphates evidently has some relation to the nerv- 
ous system, and Dowd, of Buffalo, has done some ex- 
cellent work which goes to prove, as he says, that the 
phosphatic index is the pulse of the nervous system. 

Hours could be well and profitably spent in discuss- 
ing many interesting points that are closely related to 
this subject. The relation of indican to the urinary 
findings is of itself a subject for much thought. Many 



Conclusive Researches in Metabolism 221 

hundreds of analyses have proved conclusively that 
indicanuria has an influence in the causation of acide- 
mia, and with it the diminished oxidation and elimina- 
tion which is always associated with this important and 
much neglected condition. 

In closing, let me express the hope that the con- 
tinued reiteration of the fact that the general prac- 
tician must eventually realize the need for the study of 
the metabolism as one of the first elements in the suc- 
cessful treatment of all disease will some day bring 
with it a revival of note; and if this happens, I am 
confident that with this revival will come more effective 
service, increased professional reputation and better re- 
muneration for our work. 



XXII. 

INDICAN FROM THE STANDPOINT OF THE 
GENERAL PRACTITIONER. 

Reprinted from 

AMERICAN MEDICINE, 
New York, 

December, igw. 



CHAPTER XXI L 

INDICAN FROM THE STANDPOINT OF THE 
GENERAL PRACTITIONER. 

Of all the urinary tests that have come into more gen- 
eral use during the past five years, that for indican seems 
to have taken a firmer hold on the average general prac- 
titioner than any other, and has received much promi- 
nent mention in the medical literature. The interest in 
this particular urinary finding is still growing, and right- 
ly so, for undoubtedly the presence of indican in the 
urine is a clinical factor of no mean importance and is 
deserving of the consideration of every practitioner of 
medicine. The test is not difficult and takes but a few- 
moments, and for these reasons is strongly urged on 
those physicians who may not as yet be in the habit 
of performing this test in their regular routine. 

It is generally understood that the presence of more 
than traces of indican in the urine is caused by the 
putrefaction of proteid foodstuffs in the intestinal canal, 
and this is undoubtedly the principal cause of this con- 
dition. It must be remembered, however, that the ab- 
sorption of the products of proteid decomposition any- 
where in the body will produce indican in direct ratio 
to the amount of pus present and the conditions permit- 
ting its absorption. For this reason the possibility of the 
presence of such complications as empyema, bronchi- 
ectasis, and other conditions in which there is an ex- 



226 Essays on Laboratory Diagnosis 

often the case in tuberculosis; but, too unfortunately, 
patients under treatment are usually taking altogether 
too much proteid food with the almost inevitable accom- 
panying indicanuria. 

The basic cause for the more or less complex combi- 
nation of circumstances with which indicanuria is prac- 
tically invariably found, is believed to be due to three 
important factors: 1. Rapid and excessive eating of a 
diet overrich in proteid; 2. A lack of muscular tone in 
both the intestinal and abdominal walls ; and 3. Disturb- 
ances in the normal secretory functions of the intestinal 
glands due, in all probability, to the toxemia caused by 
the motor insufficiency. 

Some investigators have called attention to the fre- 
quency with which indicanuria is associated with hypo- 
chlorhydria. Simon, of Baltimore, even suggests that the 
degree of gastric acidity may be judged by the amount 
of indican present in the urine. This may or may not 
be; probably other factors have more to do with this. 
It will be not uncommonly noted that patients suffering 
with hyperchlorhydria often show large amounts of in- 
dican. Simon himself reports having found it several 
times in gastric ulcer, with which condition an excess 
of acid is practically a constant finding. 

Unfortunately, when much was being said and written 
regarding the clinical value of indicanuria, several promi- 
nent clinicians belittled the importance of the test, said 
that indican was normally present in the average indi- 
vidual and threw cold water upon the enthusiasm of 
many who believed that they were learning to appre- 



Indican in General Practice 227 

ciate something that would be of real help to them in 
their work. Such statements are not borne out by the 
extended clinical experience of the majority; and the 
writer believes that although indican may be present 
in decidedly appreciable amounts in so-called "normal" 
urines, it is far from a normal finding and its presence 
should be an indication for prompt therapeutic action. 

It is a rare thing for a dentist to find an absolutely 
good set of teeth, neither is it common to find perfectly 
working functions in any individual. The average is 
decidedly below what we know must be a proper stand- 
ard; and because of this we cannot surely consider it 
normal for a person to have dental caries or indigestion. 
Nor, then, should we be deceived by statements to the 
effect that indicanuria is so common that it is "normal" 
and, consequently, a negligible factor. 

Granted that there is a need for the test for indican, 
how can one best perform it? In order that the general 
practitioner can be converted to the need for any addi- 
tional work it must be made plain to him that the work 
is going to be of real value to him and he must be shown 
the easiest and simplest way. So many tests for indican 
have been suggested that one is tempted to believe that 
there is no satisfactory one. Practically all tests de- 
pend upon the fact that the colorless indican — potassium 
indoxyl sulphonate — can be oxidized into the blue indigo 
by various agents in the presence of hydrochloric acid. 
The first oxidizing agent used by Obermayer was ferric 
chloride and a solution of two pro mille of this salt in 
hydrochloric acid is the commonly used reagent that 



228 Essays on Laboratory Diagnosis 

bears his name. Now, however, other oxidizing agents 
are superseding ferric chloride, simply because the Ober- 
mayer reagent is often found to contain sufficient free 
chlorine to vitiate the test; for it is well known that 
chlorine is one of our best bleaching agents and if al- 
lowed to decolorize the indigo it would lead to erroneous 
conclusions. 

It may be of value and interest to relate here an in- 
cident told to me by my friend Dr. Clifford Mitchell of 
Chicago. The doctor in his work ran across a specimen 
of urine showing an excess of indican and laid the re- 
mainder of the specimen aside to take to college that 
afternoon to demonstrate to his students. When the 
time for the test arrived, the reagents were added and 
the attention called to the "beautiful blue color" which, 
strange to say, was entirely lacking. The test was re- 
peated only to corroborate the previous finding. The 
bottle was then carefully scrutinized and was undoubted- 
ly the specimen which in the morning had showed such 
an abundance of indican. On returning to his office 
Doctor Mitchell made still another test and a deep blue 
color resulted. Evidently the trouble was with the re- 
agents, and investigation showed that the hydrochloric 
acid used at the college was not chemically pure, al- 
though supposedly so. It contained quite a large amount 
of free chlorine. 

This little incident is related here to emphasize a fact 
which I have since found out was true. From it one 
should learn that a variation in reagents may vitiate an 
indican test and that one of the essentials is to have 



Indican in General Practice 229 

"chlorine free hydrochloric acid." It might be added 
that if Obermayer's reagent is used it should be made 
comparatively fresh for the same reason. 

Amongst the other oxidizing agents which one may 
use in the indican test al*e potassium chlorate, chloride of 
lime, potassium permanganate, ammonium persulphate, 
osmic acid, sodium perborate and hydrogen peroxide. I 
have found the last mentioned reagent to be very satisfac- 
tory and practically always use it in my laboratory. It is 
very convenient, for not only is it used in general office 
work, but it happens to be used in at least two other 
laboratory tests and thus reduces the number of reagents, 
bottles and space required. 

My most satisfactory routine is as follows : To five 
cubic centimeters each of urine and pure hydrochloric 
acid add two cubic centimeters of chloroform and one 
or two drops of peroxide of hydrogen. On shaking, the 
blue color due to the liberated indigo will be seen in 
the choloroform which settles to the bottom of the tube. 
Frequently the coloration of the chloroform is very slight, 
while the supernatant fluid is dark in color. The addi- 
tion of two or three cubic centimeters of alcohol — 70 
per cent is perfectly good enough — and slight shaking 
will dissolve all of the indigo in the alcohol-chloroform 
mixture and give a much more satisfactory test. 

Frequently on shaking the mixture the chloroform 
settles in the form of an emulsion and the blue color is 
not as easily detected or measured. To obviate this Ober- 
mayer suggested that the precipitation of the substances 
which caused this trouble be accomplished with a solu- 



230 Essays on Laboratory Diagnosis 

tion of lead acetate. After the addition of this reagent 
and filtration the filtrate is tested as above. 

Mitchell in a splendid paper entitled "The Difficulty 
of the Test for Indican in Urine" (New England Med- 
ical Gazette, October 1910) advises the following pro- 
cedure: To ten c. c. of urine add six drops of "clear" 
twenty per cent solution of lead acetate (not sub-acetate, 
nor basic acetate), mix well and filter. To the filtrate 
add equal parts of Baker and Adamson's hydrochloric 
acid of a specific gravity of 1.19. Mix well, warm the 
mixture to between 105 and 115 deg. F., then add care- 
fully, without shaking, one drop of a weak bleaching 
powder solution, warm again and add a few drops of 
chloroform, warm again and so on until two c. c. of 
the chloroform have been added. Then shake vigorous- 
ly. A clear blue at the bottom shows a successful test, 
but many bubbles or a whitish emulsion shows that not 
enough lead acetate was used. Only an intense blue 
color is to be regarded as clinically significant. 

It must be evident that it is advisable to record the 
progress of an indicanuria, and for this reason some 
sort of a quantitative test is advisable. There are sev- 
eral quantitative methods, most of which are altogether 
too tedious for use in general practice. The oxidation 
of the indican to indigo in a large amount of urine, say 
500 c. c, and its abstraction by chloroform, with subse- 
quent drying and weighing is a test that is quite out of 
the question. 

The use of a standardized decolorizing solution is rec- 
ommended by Boardman Reed and for this purpose a 



Indie an in General Practice 231 

solution is used which contains one per cent of free 
chlorine (3.46 gms. of potassium chlorate in 100 c. c. 
of distilled water). After the test is made one adds 
the above solution drop by drop, shaking between each 
addition. The resulting figure is expressed as the num- 
ber of drops of the bleaching solution that are required 
to decolorize the indigo. Two drops is supposed to be 
sufficient to decolorize the indican normally present. In 
this case, or for that matter any other, it is essential 
that definite amounts of urine and all of the reagents 
are used and for convenience I suggested several years 
ago the use of a specially graduated test-tube (since 
called an "Indicanmeter") which materially facilitates 
this. This is an important point — the same amount must 
be always used if the tests are to be compared with one 
another or any standard. For routine use this decolor- 
ization test, which is usually called Robin's test, is a 
good one; and to those who are willing to spend five 
or six minutes in carrying it out, it is warmly recom- 
mended. 

The usual method is to roughly gauge the amount of 
the blue coloration and record it as zero, trace, large 
trace, excess, etc. In the brief article describing the 
above tube I referred to the possibility of producing an 
indican test-scale similar in character to the hemoglobin 
scales of Tallquist, Niemoeller or Hall. Since then two 
or three color-print scales have been produced, the best 
of which is incorporated in Dr. F. A. Faught's excellent 
little book "Essentials of Laboratory Diagnosis'" which 
the writer here takes the opportunity of recommending 



232 Essays on Laboratory Diagnosis 

very highly. 

Folin has called attention to the fact that the color 
of a fifty per cent dilution of Fehling's solution (vol- 
umetric) is practically the same as that of an indican 
test where twenty milligrammes were found in 1,000 
c. c. of urine. Basing this color as a standard, a series 
of dilutions may be made which may serve as an indican 
color scale. Unfortunately, there is a tendency for the 
copper in the solution to deposit itself on the tubes so 
that after a few weeks their value is lost. A really sat- 
isfactory printed indican test-scale showing the approxi- 
mate amounts of indican in milligrammes per liter has 
yet to be made, but will doubtless be published before 
long. 

Occasionally the choloroform after a test is colored 
red instead of blue. This is usually due to a preponder- 
ance of skatol products instead of indol products with 
a clinical significance practically the same as the blue 
indican. If the patient has been taking potassium iodide 
the red color will be due to iodine. It will quickly dis- 
appear on adding a drop of a saturated solution of so- 
dium hyposulphite (the ordinary "hypo" of the photog- 
rapher). Askenstedt of Louisville believes that the red 
or the blue color prevails in accordance with the tem- 
perature of the mixture and for this reason always brings 
his mixtures to a definite temperature before noting end 
results. Bassler in a recent contribution entitled "Red 
Indican Urine: Its Significance" (Monthly Cyclopedia 
and Medical Bulletin, October, 1910) states that: "It is 
interesting to observe that while both indicans are found 



Indican in General Practice 233 

in cases of albuminoid putrefaction in the intestines, 
urorosein (red indican) is more commonly found where 
there is putrefaction of vegetable substances, as in the 
cases of saccharo-butyric chronic intestinal putrefaction. 

"The blue indican cases usually present themselves 
clinically showing depression, relaxation, lowered vital- 
ity and persistent anemia. The red indican cases, on the 
other hand, are more usually of the irritative, anxious, 
highly neurotic and hysterical types, with good general 
body and blood conditions and are not so commonly con- 
stipated. * * * It is an almost daily observation with me 
that when the proper diet for an indican case has been 
maintained for a while (essentially proteid free) and the 
output of indican has been lowered, the individual will 
develop into a urorosein case for which the diet would 
be essentially proteid in make-up." 

An easy associated test which may be quickly made 
in conjunction with the indican test is that for indol- 
acetic acid, another product of intestinal putrefaction 
either identical with urorosein or the so-called "red in- 
dican" or at least very closely allied to it. So far as 
my experience goes, both tests may be made on the same 
specimen without difficulty. Herter suggests that to 
five cubic centimeters each of urine and HC1 one drop 
of a 1 per cent solution of potassium nitrate be added. 
If urorosein is present a rose pink coloration will ensue, 
the depth of the color being dependent on the amount 
of indolacetic acid present. The indican test may then 
be continued by the addition of the chloroform, hydro- 
gen peroxide, etc. To save multiplication J of reagents 



234 Essays on Laboratory Diagnosis 

the half per cent solution of sodium nitrite (used in 
Ehrlich's diazo-reaction) may replace the potassium ni- 
trite solution, two drops being used. 

Indolacetic acid may often be present in comparatively 
large amounts when the test for indican is negative. 
The two substances are evidently formed independently 
of one another and either or both may be present in 
any case. As Bassler suggests in his article (quoted 
above) there may be a variation in the kind of material 
that is undergoing decomposition and this be the expla- 
nation. At all events, both substances are indications for 
very nearly the same routine treatment. 

The examination of a large number of specimens has 
convinced me that when one finds a urine containing 
indican in excess, that in all probability there will be 
quite a definite sequence of associated findings. With- 
out making too positive a statement (for every rule has 
its exceptions) I believe that indicanuria is commonly 
associated with the following disturbed relations in the 
urinary findings: 1. An excessive degree of urinary 
acidity; 2. A high ammonia index; 3. Diminished out- 
put of urea, and 4. A frequent lowering of the total 
solids (in addition to the low urea-index). It will not 
be my intention to go into the details and explain the 
philosophy of these findings, save to add the suggestion 
that the circumstances which favor the production of 
indican, also favor the production of other acid bodies, 
as yet unknown, which diminish the normal blood alka- 
linity and cause complications which are by no means 
thoroughly appreciated. Hence it would seem that if 



Indican in General Practice 235 

the most is to be gained from the urine examination, 
when indican is present in excess, make special note of 
the other findings suggested above. 

The presence of a decided indicanuria is rarely not 
accompanied by other symptoms. In a few cases the 
patients are sure that "there is nothing the matter" with 
them, but more often there is a combination of un- 
pleasant symptoms, prominent among which are head- 
ache, migraine, malaise and drowsiness, a noticeable 
diminution in the capacity for work — both mental and 
physical, chronic constipation and indigestion, nervous 
irritability, fleeting pains and, often, insomnia. Anemia 
is very commonly found in these cases, and it is often 
surprising with what a bound both the red-count and 
the hemoglobin will rise when the toxemia is removed 
and indican disappears. It has been frequently noted 
that the severe anemias, chlorosis and pernicious anemia, 
are associated with indicanuria; and considerable help 
may follow the efforts made to relieve this condition. 

The treatment of indicanuria per se is no sinecure — 
it is far more than the simple unloading of the bowels 
and the removal of the putrefying material therefrom. 
Indicanuria is a habit, and the system has to be weaned 
from it. 

The first thing to do, of course, is to judiciously use 
the purge. Dietary regulation with a decrease in the 
proteid intake (especially the animal proteids) and an 
increase in the time taken to chew the food. Metchni- 
koff's bacterial therapy has proved itself of some value. 
Soured milk is much better than tablets of the germs. 



236 Essays on Laboratory Diagnosis 

Colonic irrigations are splendid and should be carried 
out daily whenever possible in every case. From one 
to three quarts of water at 80 to 90 degrees should be 
allowed to slowly enter and leave the colon as high up 
as possible. This may be continued daily for a week 
or longer. 

Another very valuable measure is the high oil injec- 
tion. From two to six ounces of cotton-seed or olive 
oil may be injected as high up as possible and retained 
all night. I have found that the addition of one or two 
per cent of ichthyol to the oil is an effective addition. 
This may be repeated once or twice and special atten- 
tion given toward dislodging any particles of impacted 
feces at the angles of the colon. 

The relief of ptosis of the abdominal walls and viscera 
is another important essential. In a paper entitled "In- 
dieanuria and Enteroptosis" (Am. Jour. Physiologic 
Therapeutics, May, 1910) the writer called attention to 
some special work that had been done along this line. 
Frequently when this is borne in mind persistent and 
intractable indicanurias disappear altogether, to stay 
away as long as the ptosis is relieved. 

There is a great deal of thorough helpfulness in this 
indican question and it is believed that further work by 
the general profession who bear this fact in mind will 
do much toward simplifying diagnoses in the "compli- 
cated cases" and making the treatment more direct and 
efficient. 

It should be added here in closing that preserved 
urines do not always give good indican tests. For this 



Indican in General Practice 237 

purpose formalin at least should never be used. Patients 
using urotropin or hexamethylenetetramine and iodine 
compounds should not take them for several days prior 
to the test. 



XXIII. 
INDICANURIA AND ENTEROPTOSIS. 

Reprinted from 

THE AMERICAN JOURNAL OF PHYSIOLOGIC 

THERAPEUTICS, 

Chicago, 

May, 1910. 
Copyright, 1910, by Henry Robert Harrower. 



CHAPTER XXIII. 

INDICANURIA AND ENTEROPTOSIS. 

The work of the clinical laboratory is not infre- 
quently of great assistance to the physician in empha- 
sizing the necessity for giving special attention to cer- 
tain conditions which, without the valuable guidance 
of the laboratory findings, might otherwise have been 
entirely overlooked. For this reason it is always ad- 
visable, when consulted by an individual for the first 
time, to see to it that a specimen of the urine is prop- 
erly collected and examined as soon as possible. With 
the report of this examination at hand one is in a bet- 
ter position to find out the disease conditions as they 
really are. 

One of the most frequent abnormal urinary findings 
is indican in excess. Considerably more than half of 
all the hundreds of specimens that have passed through 
my laboratory have shown the presence of indican in 
varying quantities, usually, however, in very evident 
amounts. That this is a mere coincidence cannot for 
one moment be considered. Many other investigators 
will corroborate the fact that indican is one of the most 
commonly found abnormal substances in the urine. Be- 
cause of this, some have gone so far as to say that indi- 
can is normally present in the urine of the omniverous 
human. This is not true. 

The ideas of those medical men who still consider 
indican to be of little or no real clinical significance 



242 Essays on Laboratory Diagnosis 

are, to my mind at least, sadly at fault. The fact that 
indican itself happens to be a non-toxic substance proves 
nothing. Without a doubt the presence of indican 
is evidence of the coexistence of other substances man- 
ufactured simultaneously. The presence of these toxic 
bodies in the blood is unquestionably harmful. Be that 
as it may, the careful investigator quickly accustoms 
himself to look for certain physical findings accompany- 
ing certain of the urinary findings, which his clinical ex- 
perience has shown him to be frequently associated with 
one another. It will not be my object here to discuss 
these various findings in detail, but rather to call par- 
ticular attention to a clinical combination which investi- 
gation has proved to be much more common than has 
ordinarily been supposed. 

The examination of a large number of specimens 
of urine, coupled, in many cases, with a careful examin- 
ation of the abdomen and its contents, leads me to be- 
lieve that enteroptosis is very often closely associated 
with the finding of indican in the urine. It would not 
be proper to construe this as a hard-and-fast rule, nor 
would it be either consistent or scientific to say that the 
majority of those showing an indicanuria are suffering 
from prolapsed viscera; but from my own experience 
I am led to believe that this condition, or, rather, com- 
bination of conditions, is more frequent than is gener- 
ally believed to be the case. At all events, it will be 
perfectly safe to suggest that the clinician make a spe- 
cially careful examination of the abdominal walls and 
the position of the various abdominal organs when the 



Indicanuria and Enteroptosis 243 

urine report shows that indican is present. 

In a recent communication Dr. Boardman Reed, of 
Los Angeles, Cal., emphasizes the frequency of abdom 
inal prolapse in pulmonary tuberculosis. He believes 
that the treatment of this disease is not complete with- 
out the suitable support of the abdominal organs if nec- 
essary. This is an important point and one worthy of 
much more extended attention. It has been found that 
the absence of indican in the urine of the tuberculous 
is the exception rather than the rule. 

Whether other investigators will corroborate these 
statements matters little; the fact remains that these 
two clinical findings — indicanuria and enteroptosis— 2 
have been repeatedly found together. As a matter of 
course, therefore, the obvious therapeutic indications 
have been acted upon in the treatment of these patients, 
with very favorable results. 

The raison d'etre of this combination is not difficult 
to explain. Indicanuria is considered by the majority 
of physiological chemists to be due usually to putre- 
factive changes in the intestinal contents. The pres- 
ence of the poisons generated under such circumstances 
must, of necessity, have an unfavorable effect on the 
intestinal walls, and especially on the glandular and 
muscular portions. In consequence the glands do not 
secrete their normal fluids and the intestinal muscula- 
ture loses its tonicity, with the inevitable dilatation, 
constipation and other accompanying symptoms. This 
very combination is an important factor in the produc- 
tion of prolapsed viscera, and, associated with the gen- 



244 Essays on Laboratory Diagnosis 

eral autointoxication which is the usual accompaniment, 
the abdominal walls become flaccid and permit of the 
gravitation of the abdominal contents. As a result the 
intestinal disturbances are rendered worse and in this 
way a vicious circle is established, which can rarely be 
remedied by the ordinary eliminative treatment. 

The removal of indican from the urine is, in most 
cases, a comparatively easy matter. Stimulation of the 
emunctories and a judiciously selected dietary in which 
the proteid content is reduced to the minimum will, in 
a reasonably short time, cause a diminution in the putre- 
faction going on in the bowel, and with it, of course, 
a disappearance of the indican. It will be found, how- 
ever, that the majority of these patients revert sooner 
or later to the old state of affairs, and the conditions 
here under discussion return and become as bad as 
ever. For this reason I am of the opinion that the usual 
therapeutic and dietetic measures are not all that might 
be desired. 

If one adds to the usual treatment outlined very 
briefly above the proper support of the abdomen by 
means of a suitable corset or binder, and emphasizes 
the importance of several dietetic maxims, such as de- 
liberate eating, simple food combinations and less meat 
or other foods high in proteids, it will be found that 
considerably better and more lasting effects will be ob- 
tained in the treatment of autointoxication, due to in- 
testinal putrefaction and its results. It would seem 
that the best support for women is the front-lacing cor 
set in which the waist is snug, but not tight. Men may 



Indicanuria and Enteroptosis 245 

use a supporter made on the same principle, but not ex- 
tending above the waist. One manufacturer here in 
Chicago is making a specialty of scientifically fitting 
such cases for the profession. 

It must not be supposed that because indicanuria 
and enteroptosis have been so often found together 
that the removal of the one necessitates the disappear- 
ance of the other. Excessive intestinal putrefaction 
may be inhibited and indican promptly disappear from 
the urine, but the prolapsed abdominal organs remain 
where they are. On the other hand, a finely fitting ab- 
dominal support may be used for months and indican still 
be found in excess. The treatment of this combination 
of conditions is evidently a matter of judiciously com- 
bining the various essentials mentioned above. 

In closing I will make the following conclusions and 
suggestions : 

1. When indican is found to excess in the urine, 
look for prolapsed abdominal viscera and the usual ac- 
companying results. 

2. When enteroptosis is evidently present, look for 
indican in the urine. 

3. In the treatment of intestinal autointoxication, 
in addition to the usual dietetic and eliminative treat- 
ment, support the abdomen. In so doing, the desired 
results will not only be more quickly achieved, but they 
will be more permanent. 

4. The treatment of chronic intestinal putrefaction 
is not complete unless special efforts are put forth to 
strengthen the abdominal walls as well as the intestinal 



246 Essays on Laboratory Diagnosis 

musculature by such physical measures as exercise, mas- 
sage, electricity (especially the sinusoidal current), 
hydrotherapy, etc. 

5. The statements of certain investigators to the 
contrary notwithstanding, indicanuria is distinctly a 
pathologic condition and must always be considered as 
such, no matter how good the general health may ap- 
pear on superficial examination to be. 

[Editor's Note.— A carbon copy of the above paper 
was sent to Dr. Boardman Reed, with the request that 
he comiment thereon if he felt so inclined. His answer, 
received just as we go to press, contains the following 
interesting statements : 

"The points in your paper are well taken. One of 
them, however, I would probably put a little differently. 
I believe that when indicanuria is present in enteroptotic 
patients, as it very frequently is, the enteroptosis has 
usually been the primary cause of the indicanuria, by 
interfering with excretion through the bowel. Perhaps 
both may have had a common cause in the very prevalent 
overloading of the stomach. Still, as is intimated, a 
vicious circle is ultimately produced in either case, and 
matters go on from bad to worse. 

"It will interest you to know that in my experience 
I have seen a number of bad cases of asthma greatly re- 
lieved, and some of them radically cured, by strapping up 
an associated prolapsed stomach and right kidney. In 
these cases there was a coexisting indicanuria which, of 
course, had much to do with the causation of the 
asthma."] 



XXIV. 

THE VALUE OF THE URINALYSIS 
IN DERMATOLOGY. 

Reprinted from 

THE AMERICAN JOURNAL OF DERMATOLOGY, 
St. Louis, 

May, 1909. 



CHAPTER XXIV, 

THE VALUE OF URINALYSIS IN DER- 
MATOLOGY. 

It is well known that many dermatoses are caused 
directly or indirectly by disturbances of the relation be- 
tween the anabolic and eliminative functions of the 
body. Frequently certain normal poisonous products are 
not properly eliminated from the system, while, on the 
other hand, an excess of abnormal waste is manufac- 
tured in the body, causing more or less serious trouble. 
These effete substances, the most of which seem to be 
acid in reaction, are carried around in the blood-stream, 
causing many inconveniences to the patient, not least 
among which are skin affections. 

Probably no one condition is as prolific in its causa- 
tion of skin diseases as autointoxication. This disease, 
if I may so call it, is very common in this country for 
several reasons. First : The irregular, sedentary life of 
the majority and the general high pressure under which 
the most of us live. Second: The excessive amount 
of food, and in particular proteid, that is usually in- 
gested. Third : The rapidity with which food is usually 
eaten. All these factors are conducive to serious dis- 
turbances which have as their direct result a general 
toxemia, and indirectly a condition of lowered vital re- 
sistance which is often associated with skin manifesta- 
tions of varying severity. 

Since the examination of the urine (and by that I 



250 Essays on Laboratory Diagnosis 

mean the complete qualitative and quantitative examina- 
tion and not simply the mere testing for specific gravity, 
sugar or albumin that is so often done) affords such a 
clear insight into the actual conditions present in the 
body, this routine is of great value to the physician in 
his practice. It opens up new fields for therapeutic ac- 
tivity, which, without the findings of the urinary exam- 
ination, would either be unnoticed or not fully appre- 
ciated. Particularly is this true in the practice of der- 
matology, because of the very close connection between 
certain skin diseases and the metabolic activities of the 
body. 

It is surprising how many skin affections are asso- 
ciated with acid intoxication or acidemia. Acne, herpes, 
eczema, pruritus and many other conditions seem, from 
results obtained in their treatment, to be entirely due to 
this condition. This is at least true in some cases, for 
when the offending cause is removed and the poisonous 
substances present are properly neutralized and elimi- 
nated from the body, the offending skin lesions disappear 
.without further attention, in the majority of cases. 

The examination of the urine is a measure which 
should be carried out as a routine in every case, not 
only in dermatology but also in general medicine. The 
urinary examination offers a number of definite find- 
ings associated with acidemia and autointoxication, the 
most important of which are the presence of indican 
and indol-acetic acid, both of which are products of pro- 
teid putrefaction in the body, together with an excessive 
degree of acidity. 



The Urinalysis in Dermatology 251 

A factor of vital importance, which has as yet not 
received the attention that it merits, is the urinary acid- 
ity. Unfortunately, the medical profession still believes 
in the textbook statements that the test for acidity or al- 
kalinity with litmus paper is sufficient ; but this is not so. 
In every case the degree of acidity should be accurately 
estimated and the relation of the degree of acidity to 
the amount of urine passed in twenty-four hours care- 
fully ascertained. 

Dr. A. L. Benedict of Buffalo, N. Y., has shown 
that the relation between the acidity and total amount 
is important. This is termed an "acid-unit" and is ob- 
tained by multiplying the degree of acidity of a speci- 
men from a mixed 24-hour collection by the amount (in 
cubic centimeters) passed. The average normal number 
of acid-units is about 40,000 in 24 hours, corresponding 
to 1,000 c.c. of urine of 40° acidity or 1,300 of 30°. 

The quantitative estimation of these factors is un- 
doubtedly of considerable value, as they are very closely 
related with other abnormal urinary findings. The ex 
cessive acidity which is so common is due to certain acid 
substances manufactured during the process of the de- 
praved metabolic conditions practically always associ- 
ated with intestinal putrefaction. 

The most common dermatosis — acne vulgaris — is 
almost invariably associated with a greater or less de- 
gree of autointoxication, as probably the most frequent 
exciting cause is a disturbance of digestion with an 
accompanying constipation. In these cases an examina- 
tion of the normal products of metabolism eliminated 



252 Essays on Laboratory Diagnosis 

m the urine very often makes plain the way for suc- 
cessful treatment. 

Conditions previously assumed to be due to some 
basal neurotic difficulty, as, for example, herpes, will 
be found in the majority of cases to evidence in a 
marked degree the findings associated with autointoxi- 
cation, and particularly to show an excessive degree of 
acidity. One case of herpes zoster of very long stand- 
ing which comes to my mind showed the following 
urinary findings: Amount 1,250 c.c, specific gravity 
1,014, total solids 40.75 grams, acidity 78 degrees, acid- 
units 97,500, urea 1.1 per cent., indican much, with 
traces of indol-acetic acid. 

Thorough elimination by the use of calomel in broken 
doses, a saline each morning, with intestinal antiseptics 
and neutralization of the acidemic condition, resulted in 
a remarkable amelioration of the condition. The ecu 
tinuation of the local remedy which had been previously 
prescribed for this lady, together with this modification 
of the systemic acidity, caused a serious condition of 
long standing to disappear within a month. This, of 
course, is only one case, but many other skin diseases 
have responded remarkably to the systemic treatment of 
those conditions evidenced by definite urinary findings. 

The laboratory examination of many hundreds of 
specimens of urine, passed in every case by individuals 
whose condition was far from the normal, shows con- 
clusively that many unpleasant symptoms (very com- 
mon ones of which are skin eruptions and irritations) 
and even dangerous conditions are closely associated 



The Urinalysis in Dermatology 253 

with and possibly directly caused by excessive urinary 
acidity and those disturbed metabolic relations causing 
this condition. In a series of 250 cases recently reported 
by me in the Medical Record the average acidity was 
60 degrees, the lowest being ten degrees and the high 
est 274. The acid-unit index varied from 100,000 to 
200,000 per day; the minimum in this series being 8,030 
and the maximum 358,050. In 25 per cent of these 
cases casts and traces of albumin were found, and in 
83 per cent indican was present to a greater or less ex- 
tent, usually in large amounts. 

Another fact of considerable importance was the 
findings regarding urea. In these 250 cases the amount 
of urea eliminated was reduced an average of 50 per 
cent of the percentage normally eliminated in 81 per 
cent of the whole series, showing definitely that the 
condition of high acidity is very frequently if not prac- 
tically always associated with a lowered urea output and 
a marked indicanuria. 

Of course, the most important part in this paper 
will be the therapeutic indications of these findings. In 
my estimation, every individual suffering from dermal 
affections, no matter how insignificant or how severe, 
should have a complete urine examination. The ortho- 
dox local and systemic treatment may be very satisfac- 
tory, but it should always be supplemented with thor- 
ough elimination, repeated frequently, and a neutraliza- 
tion of the hyper-acid state of the body, using the urin- 
ary acidity as the index. This can be easily accom- 
plished by the cautious use of alkalies, and it will be 



254 Essays on Laboratory Diagnosis 

surprising how many cases in the routine work of the 
skin specialist will yield to treatment along these lines. 

From the foregoing it must not be supposed that 
alkalies are a panacea for all skin diseases, but when 
the urinary findings show an excessive degree of acidity 
and this is brought down to normal by the judicious 
use of alkaline remedies, guided always by the acid in- 
dex, success will often be attained. 



XXV. 

THE LIFE INSURANCE "URINE EXAMINA- 
TION"— A FARCE. 

Reprinted from 

AMERICAN MEDICINE, 
New York, 

October, 1909. 



CHAPTER XXV. 

THE LIFE INSURANCE "URINE EXAMINA- 
TION"— A FARCE. 

From the above heading many readers will undoubt- 
edly expect to see some decided statements, and their 
expectations will be gratified. It is admitted that the 
thought embodied in the title of this brief article is 
fairly strongly stated, but, at the same time, it is to my 
mind absolutely true, and there are many medical jour- 
nals of repute which are not afraid to publish an ar- 
raignment, so to speak, of the present methods of 
urinalysis in general practice, and, in particular in the 
analysis made in the routine examination for life insur- 
ance. 

I believe that I am not overstating matters in the 
least when I say that the urine examination properly 
performed and as extensive as circumstances will per 
mit, is one of the most important single diagnostic pro- 
cedures that we have. By saying this, I do not imply 
that other methods of precision are not valuable, but 
none of them gives as many pointers, either diagnostic 
or therapeutic, as the one series of tests called the urin- 
alysis. 

All reputable life insurance companies naturally de- 
mand a thorough examination of the prospective appli- 
cant for protection, in order that their medical directors 
and those under them can decide whether a case is 
worthy to receive a policy or not, so that their risks 
may be as sure as possible. I have had some slight ex- 



258 Essays on Laboratory Diagnosis 

perience as an examiner for the Metropolitan Life In 
surance Company, and have seen a number of the ex- 
tended blanks of several other large companies which 
the medical examiners are expected to fill out in the rou- 
tine of the so-called "medical examination." Both the 
old-line and the fraternal companies require careful med- 
ical examinations. The urine examination is usually part 
of the procedure, and it is about this examination that 
I wish to express a few thoughts. 

Frequently the examiner is expected to receive a 
small specimen in his office; no special effort is made 
to have a part of a mixed twenty-four-hour collection, 
and some companies prefer a specimen passed right in 
the office, thus eliminating the possibility of substitution. 

The specific gravity is usually ascertained with the 
crude 35-cent urinometer so frequently found in the av- 
erage physician's office. The urine is then boiled and 
perhaps Heller's test for albumin is carried out Either 
the Fehling or Haines method is advocated for the de- 
tection of sugar. Some companies require more than 
this, but they are few and their requirements are not 
very much more extensive. 

Let us dissect such urine examinations and the pos- 
sible findings as mentioned above. Suppose the specific 
gravity is above the limit usually mentioned in the in- 
struction books to company physicians. Is it not entirely 
probable that the examination for specific gravity of an 
individual passage of urine passed during the summer 
months will show a specific gravity of from 1,025 to 
1,030? Is it not possible for an individual to have par- 



The Life Insurance Urine Examination 259 

taken quite freely of nitrogenous food, or to have made 
use of a little more than the usual amount of table salt, 
and in this way increase the specific gravity of his speci- 
men? On the other hand, is a specific gravity of 1,008- 
1,010 not of common occurrence when the individual 
has drunk freely of water, especially when specimens 
are taken at random? 

Again, the test for albumin is another source of 
trouble. A positive reaction does not occur in many 
cases which evidence renal disturbances, and often traces 
of albumin may be present when there is no serious 
disease. I am acquainted with several individuals, and 
have heard of many others, who have been refused life 
insurance for the simple reason that there was a trace 
of albumin in their urine. Is there not such a thing 
as alimentary albuminuria? Is it not possible for albu- 
min in the urine to be there temporarily, just the same 
as an excess of chlorides or a diminution in the phos- 
phates? As a matter of fact, in my experience, which 
-covers a number of hundreds of examinations, I have 
found that albumin, and even casts are comparatively 
frequently found associated with an excessive degree 
of urinary acidity — a condition which, when properly 
treated, may be speedily ameliorated with a resultant 
disappearance of both casts and albumin. 

It is not to be presumed from the statements above 
that the presence of albumin in the urine is a matter of 
minor importance to be neglected or overlooked. A 
persistent albuminuria is usually evidence of something 
abnormal, and if the associated functional abnormali- 



260 Essays on Laboratory Diagnosis 

ties are modified and the albumin still persists, there is 
probably an organic disturbance. In this case, of course, 
the insurance risk is bad. 

The test for sugar is usually crudely carried out by 
more or less unskilled hands, and very frequently in a 
big hurry. Fehling's solution is the most common rea- 
gent, and is by no means infallible. A number of sub- 
stances are known which reduce this and other copper 
test-solutions, and since this is a fact, would it not be 
well to be sure that the reducing substance present is 
positively sugar? For this reason the phenyl-hydrazine 
test is suggested, or, as a fair substitute, the fermentation 
test. And even if sugar — real, unadulterated glucose — 
is present in small quantity, the one examination is not 
enough, for it is entirely possible to have a condition of 
alimentary glycosuria. 

As I have written before in other articles, a urine 
examination comprising only the tests mentioned above 
— specific gravity, albumin and sugar — is a very crude 
procedure. It might well be much more extensive and 
give the examiner information of much more extended 
value. For this reason I would suggest as a matter for 
thought the advisability of having the urine examination 
which accompanies applications for insurance for $1,000 
or more, made by an expert who knows how to do the 
work properly, said examination to include in addition 
to the usual physical measures, the chemical examina- 
tion for albumin, sugar, bile, blood and indican and a 
quantitative examination for urea, acidity, ammonia and 
perhaps chlorides and phosphates. In addition to this, of 



The Life Insurance Urine Examination 261 

course, a careful microscopical examination of the cen- 
trifuged sediment should also be made. 

From such an examination it would be evident wheth- 
er the individual was in a normal state of metabolic 
equilibrium ; whether there was a disturbance of the kid- 
neys or any other part of the urinary tract; whether 
there was an excessive degree of intestinal putrefaction, 
or other gastro-intestinal disturbances. In short, it 
would be a measure of real diagnostic value. 

What is worth doing at all is worth doing well, and 
I contend, therefore, that if the examination of the urine 
has been found necessary and advisable in life insurance 
practice, that it might as well be done thoroughly. This 
naturally also applies to the urinalyses accompanying all 
physical examinations, whether for therapeutic sugges- 
tions or what-not. 

Conclusions: 1. The examination of the urine, and 
especially that made for the benefit of life insurance 
companies, is altogether too crude and not nearly ex- 
tensive enough. 2. Because of this, individuals are be- 
ing refused life insurance who would make excellent 
risks, and, on the other hand, others are "passed" who 
are by no means what might be called healthy, and, in 
fact, are in a serious condition. 3. The examination 
should be made by such as are skilled in this work, and 
should be paid for accordingly. Three dollars is not an 
unreasonable figure. 4. There is room for considerable 
improvement in the work at present done along those 
lines, and it is to be hoped that with frequent and per- 
sistent stimulation progress may be eventually secured. 



XXVI. 
METABOLISM AND MOUTH-DISEASE. 

(A paper read before the Section on Stomatology, American 
Medical Association, St. Louis, June, 1910.) 

Reprinted from 

THE JOURNAL OF 

THE AMERICAN MEDICAL ASSOCIATION, 

Chicago, 

October 1st, 1910. 

Copyright, 1910, by American Medical Association. 
Reprinted by permission. 



CHAPTER XXVI. 
METABOLISM AND MOUTH-DISEASE 

Since there is a very close relationship between the 
functions of the various organs of the body, it is not 
unreasonable to suppose that disorganization in one part 
will be accompanied or followed by disturbances else- 
where. From a study of conditions as they are today in 
t>oth medicine and dentistry, however, it would seem that 
this important fact is not as fully appreciated as might 
be expected. 

It is generally believed that certain more or less in- 
tractable diseases of the mouth or its contents are, to 
a greater or less degree, either accompanied by or asso- 
ciated with changes in the normal metabolic functions 
of the body. In spite of this, comparatively few physi 
cians are stimulated to look carefully into the mouth 
when evident errors of the metabolism are known to be 
present ; nor do our dental confreres investigate the meta- 
bolism of those of their patients who are suffering from 
the all-too-common and intractable mouth diseases. 

This is not as it should be, for any local manifestation 
of disturbed function should serve as a reminder that a 
thorough investigation is not only necessary, but imper- 
ative. This is just as true of mouth diseases as of stem 
eruptions, joint difficulties or gastro-enteric disorders. 
All too often Nature's glaring sign-posts are ignored. 

Without a doubt there is a very close relationship 



266 Essays on Laboratory Diagnosis 

between the condition of the buccal mucosa, the gums 
and teeth, as well as the tongue, and the blood which 
nourishes them. From time immemorial the condition 
of the tongue in disease has been used as an important 
diagnostic sign, and the study of this is given a promi- 
nent place in the text-books and current medical litera- 
ture. For this reason I give it merely passing mention 
here. 

It might be well here to quote a few lines from a 
valuable editorial entitled "Gingivitis in Diabetes" print- 
ed in a recent issue of The Journal : "The importance 
of mouth symptoms in the acute infections, such as scar- 
let fever, diphtheria and measles, is recognized. It is 
less generally known, however, that in many constitu- 
tional conditions the mouth secretions and the mucous 
membranes covering the gums, cheeks, tongue, etc., fur- 
nish early and positive data for diagnosis. 

"It becomes a matter of extreme importance, there- 
fore, that the general practitioner shall examine the 
mouths of all patients, taking careful note of the mucous 
membrane of the cheeks, beneath tne tongue, on tne 
tongue itself, the roof of the mouth, and especially the 
gums." 

The work of a number of broad-minded investigators,, 
among whom the esteemed secretary of this Section, 
Dr. Eugene S. Talbot, stands pre-eminent, has called the 
attention of both the medical and dental professions ta 
the relationship between pyorrhea alveolaris and certain 
blood dyscrasias. This subject is of paramount import- 
ance and one to which much more attention should Be 



Metabolism and Mouth-Disease 267 

paid. Here we have a vital factor in the solution of a 
multitude of difficulties, not merely pyorrhea alone, nor, 
for that matter, mouth diseases per se, but of a long list 
of common and uncommon conditions which embrace 
almost all the diseases known to medicine. It is a fact 
that as a profession we have not yet fully grasped the 
meaning of the Biblical statement, "The blood is the 
life/' I do not mean by this that we do not appreciate 
the fact that life is dependent on the blood and its 
healthy condition, but the fact that in the majority of 
cases disease is due to toxic wastes which are present in 
the blood-stream and which unquestionably markedly 
lower its disease-resisting powers. 

These poisons are not all of them sufficiently well 
known to have been isolated and named, but their fre- 
quent presence and easily demonstrable untoward effects 
are apparent to all that take the trouble to look for them. 

Principal among these disease-producing toxins are 
certain acid substances which have been demonstrated 
to be closely related to indican and other products of 
intestinal putrefaction. Just what these substances are 
remains to be proved, but that they are acid in reaction 
and that their baneful influence is evident in the mouth 
as w r ell as throughout the whole system is very quickly 
and easily proved. 

Our methods of analyzing the blood and estimating 
its alkalinity are altogether too complicated for general 
use. In their place the examination of the urine has 
been found to be at once convenient, quick and easy; 
and the results obtained from such examination will be 



268 Essays on Laboratory Diagnosis 

found at times to be even startling. Probably the one 
factor obtained by the careful analysis of the urine which 
in most cases overtops its fellows is the acid-index, and, 
strange to say, hardly more than a mention of it and 
the method of its estimation is to be found even in the 
most recent text-books. 

Let us for a moment consider the question of the 
urine analysis and the relations of some of the findings. 
The urine is usually acid in reaction and the average 
normal acidity ranges from 30 to 40 degrees (each de- 
gree represents the amount of decinormal soda solution 
required exactly to neutralize 100 c.c. of urine). This 
acidity, we are told, is due to certain acid salts, principal 
among which is the acid phosphate of soda. We learn 
from the text-books that the urinary acidity is very dif- 
ficult to accurately estimate because of the trouble in 
securing an indicator which will be more responsive to 
all the various acid salts, and probably for this reason 
the study of this most important finding has been largely 
passed over. 

Phenolphthalein is the most satisfactory indicator and 
is used by the majority of investigators. The test is 
simplicity itself and is fully as accurate as many of the 
well-known and widely used tests, as, for example, the 
albumin tests of Esbach or Purdy, or the Doremus 
urea test. The acidity of the urine should always be de- 
termined from a portion of a complete twenty-four-hour 
specimen, and care should be taken to prevent, as far 
as possible, alkaline decomposition of the urine. Either 
a burette or my acidimeter may be used. The latter is 



Metabolism and Mouth-Disease 269 

far more convenient for the physician or dentist in his 
office, while the former is probably better in routine 
laboratory work where large numbers of specimens are 
beTng handled. 

In a paper published last June I called attentiorSTto 
the frequency with which excessively acid urine accom- 
panied indicanuria and a marked diminution in the 
amount of urinary solids passed. A series of 250 analy- 
ses was mentioned in this paper. These findings, aug- 
mented by much further work along this line both by 
myself and several interested friends, was reported in 
a paper read at the annual meeting of the Illinois State 
Medical Society held last month. 

From my findings it would seem, to me at least, that 
we have conclusive evidence that in the study of the 
urinary acidity we have something of more than ordi- 
nary importance. The relation of this syndrome of find- 
ings — acidemia evidenced by a hyperacid urine, intes- 
tinal toxemia by indicanuria, and decreased metabolic 
activity by the frequent low urea index and general re- 
duction in the total solids — to mouth-disease, is quickly 
found. It is safe to say that a majority of patients 
suffering from pyorrhea are acidemics, and the mdst 
conclusive feature of this work is that therapeutic meas- 
ures calculated to reduce the acidemia and eliminate the 
toxemia have a decidedly beneficial effect on the pyor- 
rhea. 

Many patients have been examined by me personally. 
Dr. Talbot has made hundreds of examinations and sev- 
eral others have by their work proved absolutely that 



270 Essays on Laboratory Diagnosis 

there is decided and close connection between disturbed 
metabolism and mouth-disease. 

I might go further and discuss the relations of the 
metabolism as evidenced by the urinary findings to dis- 
eases of the buccal mucosa, the pharynx and the tonsils, 
but this is a subject far too broad to be touched on as 
briefly as would be necessary here. 

It is hoped that a widespread study of the relations 
between the disturbances of metabolism and mouth af- 
fections will shortly be inaugurated among the rank 
and file of the professions, and that the dentists as well 
as the doctors will come to see the important influence 
that the hyperacid state plays in disease causation in 
general and in mouth disorders in particular. 



XXVII. 

THE IMPORTANCE OF THE CLINICAL 
LABORATORY IN SURGERY. 

Reprinted from 

THE AMERICAN JOURNAL OF SURGERY, 
New York, 

October, 1910. 



CHAPTER XXVII. 

THE IMPORTANCE OF THE CLINICAL LAB- 
ORATORY IN SURGERY. 

Every surgeon realizes that his work does not sim- 
ply consist in performing operations. There is a great 
deal more to an operation than the removal of diseased 
tissues, and if the surgeon's mind is not too firmly fixed 
on the operative condition, but is trained to include every 
helpful or hindering factor, ultimate success — not merely 
surgical success — will be the result of his work. 

It is generally considered that the facilities of a clin- 
ical laboratory offer the surgeon much assistance in 
gaining a general insight into his patient and his inner 
workings. Laboratory investigations have come to be 
imperative procedures prior to an operation, and, again, 
in many cases the laboratory is made an efficient guide 
to the post-operative treatment. 

When a physician situated in a large city has a case 
requiring surgical attention, the hospital is naturally one 
of his first thoughts. One rarely finds a surgeon oper- 
ating upon his patient at home unless the case happens 
to be one of great emergency, or there is marked antip- 
athy to the hospital. Indeed, today it is customary for 
both laity and profession to immediately associate the 
thought "operation" with "hospital." This is, of course, 
right and proper, and the advantages provided by an up- 
to-date hospital are essential to the convenient prepara- 
tion and after-care of the patient. But the advantages 



274 Essays on Laboratory Diagnosis 

of the hospital do not consist simply in a splendidly 
equipped operation room and the various paraphernalia 
used in or near it, but also — and this is by no means the 
least important — in the clinical laboratory, in which the 
various essential investigative measures can be conven- 
iently and thoroughly carried out. 

For this reason the laboratory and its work have be- 
come a matter of comparatively little concern to the city 
physician or surgeon, since his telephoned instructions 
are to "Make a blood examination for X.," "Have Y's 
urine carefully examined, ,, or whatever the exigencies 
of the case demand. In many cases there is a standing 
order for a definite laboratory routine which is carried 
out in every case. 

This is as it should be ; but, unfortunately, frequently 
there is not quite as much interest evinced in laboratory 
methods among the surgically inclined physicians who 
happen to be situated in those districts where laboratory 
facilities are not so convenient as in the city and the 
work is not so easily done as by simply ordering it over 
the telephone. While the fact cannot for one moment 
be contended that the need is just as great whether in 
the city or in the country, this is not often appreciated, 
and all too frequently the perfunctory test of a single 
specimen of urine for albumin and sugar constitutes the 
sum total of the "laboratory work" done by many provin- 
cial surgeons. For this reason it would seem that more 
attention must be given by many physicians to the im- 
portance and advantages of laboratory help in surgery. 

Of course, it is easily understood that many surgical 



The Clinical Laboratory in Surgery 275 

conditions are diagnosed by laboratory procedures and 
in many more the tentative diagnosis is definitely estab- 
lished after, say, a blood examination or some other lab- 
oratory investigation. Still, to my mind the laboratory 
offers the surgeon its very best services in laying bare 
the other important conditions present in his patient 
which, if overlooked, might prove a serious menace, or, 
at least, a hindrance to the successful outcome of either 
the operation or the anesthesia. 

The urine examination is one of the most import- 
ant pre-operative diagnostic procedures. The urine of 
every individual upon whom an operation is expected 
to be performed should always be carefully examined 
prior to the operation at least once. Two or three times 
would be much better, since sometimes certain urinary 
findings may be unusually marked or entirely absent in 
one single specimen. The examination for albumin alone 
is not sufficient, for its presence is not necessarily evi- 
dence of structural kidney disease, nor, for that matter, 
need the finding of hyaline casts be considered as se- 
rious. These tests, of course, are not valuable unless 
the functional capacity of the kidneys and liver, as well 
as the metabolism in general, are also known. The phy- 
sician who neglects to study these points is overlooking 
possibilities which may be of prime importance to the 
success of his work. 

Naturally, if organic renal disease is present the an- 
esthetist hesitates to administer a general anesthetic. Is 
it not just as dangerous to contend with other conditions 
that are not evidenced by the crude and practically worth- 



276 Essays on Laboratory Diagnosis 

less tests that are commonly used? The importance of 
the relation between the normal elements of the urine, 
as well as the presence of abnormal elements, should 
receive just as careful attention, for from these figures 
a far better idea of the metabolism may be obtained. 

It is well known that certain insidious disturbances 
of metabolism may be present in an individual without 
any decided symptoms to warn him of this fact. It is 
quite reasonable to suppose that a tolerance to these con- 
ditions may be interrupted or entirely lost when he suf- 
fers from a severe traumatism or the heavy burden of 
a general anesthetic. For this reason it is believed that 
the urine should always be quantitatively tested for acid- 
ity, total solids, urea and indican, in addition to the 
other tests for abnormal elements such as albumin, /glu- 
cose and the acetone bodies. It might be well also to 
include in the routine a test for occult blood and bile, 
for obvious reasons. 

Attention should be given to the acidity of the urine, 
for it has been found to be a very reliable guide to the 
general vital resistance. It is well known by physiolo- 
gists that upon the proper maintenance of the normal 
alkalinity of the blood depends the proper carrying out 
of its normal functions ; in other words, if the alkalinity 
is reduced, the normal interchange of gases cannot take 
place, phagocytosis is disturbed, and the resistance of 
each microscopic cell structure is materially diminished. 
This would seem to be an important factor in the pre- 
operative investigation of a patient, since many surgical 
operations, as gynecological operations, are done after 



The Clinical Laboratory in Surgery 277 

considerable premeditation, and not on the spur of the 
moment. In these cases, at least, it is reasonable to 
presume that both patient and physician are anxious to 
have every circumstance as propitious as possible, and 
in my opinion a patient coming for an operation with a 
urine showing the total acidity to be increased two or 
three hundred per cent is not in the best condition either 
to stand the anesthetic or to recuperate after an opera- 
tion. 

The general conditions that are associated with a 
marked diminution in the amount of urinary solids, and 
especially urea, are of paramount importance. It must 
be remembered that not only is there frequently a rela- 
tion between low solids and renal disease, but very often 
it will be found that the liver and thyroid are not func- 
tionating as they should. When this is the case, and the 
solids are less than half the normal that should be passed 
in twenty-four hours, the circumstances are not nearly 
as favorable to a successful outcome of an operation as 
though they were practically normal. 

The condition of the bowel must needs be a prolific 
cause of diminished resistance and undoubtedly advances 
have been recently made in the study and appreciation 
of these conditions and the findings associated with them. 
Autointoxication must be considered as an absolute con- 
traindication to all save emergency operations. The 
presence of indican in the urine should always receive 
attention, although it is granted that indican itself may 
be an entirely innocuous substance. It is reasonable, 
however, to suppose that the conditions which excite 



278 Essays on Laboratory Diagnosis 

its manufacture are, to say the least, not the most favor- 
able to recovery after a serious operation. 

It will not be my endeavor here to go into the dis- 
cussion of the importance of sugar in the urine from the 
surgeon's standpoint. It is generally known that there 
is a greater danger of coma supervening after an opera- 
tion upon a patient suffering from diabetes, and this fact 
should always be properly weighed before operating. 
Attention has been called by some writers to the dan- 
ger of coma following operations on diabetics that had 
been supposedly cured for several years. 

The acetone bodies are of even greater significance 
than sugar, for upon their presence depends the acidosis 
which is so dangerous. The ammonia-index is another 
factor which must not be neglected. This, in connec- 
tion with the acidity, will give one an excellent idea of 
the condition of the metabolism and elimination of any 
patient. 

There are many other procedures practiced in the 
laboratories besides the urinalysis, and many of them 
may be made of immense value to the surgeon. I need 
only mention the recent work that has been done with 
vaccine therapy and how some progressive surgeons, no- 
tably W. H. Hutchings, of Detroit, are now immunizing 
their patients by injecting doses of polyvalent vaccines 
before operating, and thus precluding the possibility of 
an infection. 

The examination of the blood, both to gain an idea 
as to its upbuilding powers (hemoglobin and red cells), 
as well as the determination of the presence of leucocy- 



The Clinical Laboratory in Surgery 279 

tosis, are too well known to be dwelt on here. Yet, it 
is strange that so many times no recourse is had to this 
invaluable test, and a comparatively simple appendicitis, 
for example, is allowed to become gangrenous. The 
whole subject of the blood examination from the surgical 
standpoint is admirably discussed in a splendid book by 
Ira S Wile, of New York, which every surgeon should 
have and read. 

Another matter of importance which has received 
very little attention is the estimation of the coagulability 
of the blood. Many times a surgeon has had a "close 
shave" by operating upon a patient with hemophilia, or, 
at least, a diminished calcium content of the blood. If 
the actual investigation is impossible, it is easy to con- 
sider every patient a "bleeder" and give him sufficient 
calcium (15 grains calcium lactate t. i. d. for three or 
four days prior to operation) to reduce to a minimum 
the hemorrhage which the operation might cause. 

The examination of sputum, feces, pus, and various 
body fluids needs only to be mentioned in passing. The 
diagnosis of various malignant conditions by the exam- 
ination of stained sections of tissue must not be forgot- 
ten. In closing, I would like to lay particular stress 
upon the need for a great deal more laboratory work 
in the surgical part of the practice of the average phy- 
sician, and especially upon the advantages which the 
complete examination of the urine, both before and after 
operation, may bring with it. 



XXVIII. 

THE TWENTY-FIVE DOLLAR^ 
LABORATORY. 

Reprinted from 

THE MEDICAL WORLD, 
Philadelphia, 

March, 1911. 



CHAPTER XXVIII. 

THE TWENTY-FIVE-DOLLAR OFFICE 
LABORATORY. 

Most physicians have an idea very firmly engrained 
into their minds that the equipment of an office labora- 
tory is a very expensive matter. They always think 
first of the microscope, and its cost— $50.00 to $100.00— 
often suffices to deter them from making the step and 
starting out to fit up a little laboratory for their per- 
sonal use. 

I am not going to deny the fact that the microscope 
is a most important part of the equipment of any clin- 
ical laboratory, but simply because one cannot invest in 
such a seemingly expensive piece of apparatus, it by no 
means follows that no clinical laboratory work can be 
accomplished without it, or that unless a microscope can 
be bought it is not worth while beginning. 

Many requests have come to me from physicians who 
want to know what they can do to fit up a small labora- 
tory and start out in a reasonably decent way without 
incurring too great an expense and "going in over their 
heads." Time and again I have started to work out 
something that might be helpful to these correspondents 
and others similarly interested into whose hands these 
suggestions might fall, and as often have been pre- 
vented for some reason or another. 

Let us first set a figure as a maximum and see what 
can be done within this limit. Suppose that we put our 



284 Essays on Laboratory Diagnosis 

limit at $25.00. Not a very large sum, and, probably, 
within the reach of every reader of The World who 
is actuated by the desire to gather the fruits which 
always come to those doing this kind of work. If one 
is absolutely convinced of the necessity of adding to his 
equipment and professional capacity by the purchase of 
$20.00 or $25.00 worth of apparatus, it will not take 
him long to find the money, especially when he realizes 
that a week or so of the new era in his work will more 
than repay him for the actual cash expenditure, not to 
mention the peculiar advantages w r hich invariably follow 
the better knowledge, better service and better results 
thus obtained. 

The first thing to be considered is the place to work. 
Much of my own work has been done right in the office 
in front of the patient while I was conversing with him. 
This saved my time, proved to my patient that I did 
more than throw the specimen down the sink when his 
back was turned and created an interest both in my skill 
and their condition, which had a decidedly favorable in- 
fluence on both the readiness with which I received my 
fee, and also upon the mental state of the patient relat- 
ing to his physical condition and its variations. I used 
a glass-topped table such as is manufactured by the W. 
D. Allison Company for specialists. Around three sides 
of the top is a low wooden rail on which bent metal re- 
ceptacles are fixed which allow of the secure placing of 
the bottles. Under the glass top is a cupboard with glass 
sides and a white glass bottom, and beneath that were 
half a do^en small and convenient drawers. The table 



The Twenty-Five-Dollar Laboratory 285 

cost $30.00 or more, and, therefore, it will be quickly 
passed by with no more than this brief mention. 

Instead of this, I would suggest a shelf attached to 
the wall about five feet from the floor and three and a 
half or four feet long. Immdiately below this and at a 
height of 32 or 44 inches is another shelf of the same 
length, twelve inches wide (the width of the widest 
boards in regular stock at the lumber yard) and one 
inch thick. This is securely fastened to the wall, and 
so arranged that another board of the same length and 
width may be attached with strong hinges to it and held 
up with braces, or hung down when not in use, after 
the style of some tables, thus saving space if the office 
is not large. 

Drill a hole at 'one end of the shelf near the wall and 
into it place a large-sized (8-inch) funnel to which a 
piece of rubber hose has been attached. On the floor 
place a large butter-crock to act as a waste reservoir. 
This serves in place of a sink and is very convenient 
where there is no plumbing. Of course, some will be 
fortunate in having a little room where there is running 
water, a sink and a nice bench. At all events, I will not 
count in our $25.00 the cost of carpenter work or the 
improvised plumbing. 

It is remarkable how much laboratory equipment can 
be dispensed with when it becomes necessary, and how 
much effective work can be done — and done well — even 
with the simplest of tools, It may surprise many when 
I say that it is the exception rather than the rule for 
me to use a burette! Never have I had one in my of- 



286 Essays on Laboratory Diagnosis 

fice, although, of course, when I was doing special lab- 
oratory work all day long, I had several in my labora- 
tories. 

In place of the burette I use a simple instrument de- 
vised by me, which I call an "acidimeter." With this 
little graduated tube it is possible to estimate the urinary 
acidity (or alkalinity), the urinary ammonia, the gastric 
acidities (including free HC1, total acidity, combined 
acidity and total HC1). It is a handy little thing and, 
modified to use for the ammonia estimation, costs only 
$1.50. (Before I conceived the idea of utilizing this in 
the Malfatti ammonia estimation it was graduated to 
100 degrees, instead of to 150 degrees as now, and then 
sold for $1.25.) 

The Doremus ureometer is an essential. The variety 
which requires a foot, or the more complicated Doremus- 
Hinds instrument, is not recommended. The usual price 
of the simplest form of this instrument is from 75 cents 
to $1.00, and this includes a graduated pipette. 

For the estimation of glucose in the urine, the Ein- 
horn saccharimeter is recommended. This costs $1.00 
and needs no other reagents than a small piece of fresh 
yeast, which may be procured at any grocer's. 

Albumin is estimated by means of Esbach's albumin- 
ometer, using Tsuchyia's phosphotungstic acid solution 
instead of the older picric-citric acid solution. Some 
years ago I devised an albuminometer for use with the 
phosphotungstic acid mixture which, instead of depend- 
ing upon the estimation of how much albumin there is 
in a given amount of urine, permits of the estimation of 



1 lie Tzventy-Five-Dollar Laboratory 287 

the amount of urine containing a given amount of albu- 
min. For this reason it is much more accurate than the 
precipitation method. It takes only a minute or two 
instead of 24 hours, but has one disadvantage which has 
hurt it somewhat. There is "a personal element" in the 
test; the reaction consists in noting the first appearance 
of a white cloud, and often some see, or imagine they 
see, the cloud before others, and consequently there is 
an element of error which has deterred some from using 
this instrument. By no means all feel thus, and many 
are making their albumin tests in a minute whereas be- 
fore it took very much longer. The Esbach instrument 
can usually be bought for 50 cents ; Harrower's albumin- 
ometer costs $1.00. 

The centrifuge is an excellent piece of apparatus to 
have, but it can be dispensed with if necessary, and for 
this reason the Purdy method of estimating albumin is 
not recommended here. 

A simple instrument called an indicanmeter, also de- 
vised by me, has some noticeable advantages in routine 
work. It enables one to make careful comparative in- 
dican estimations that are dependable. It costs $1.00, 
but can be easily made by carefully graduating a test 
tube and marking off the proper places with some hydro- 
fluoric acid. 

Some physicians feel that they should estimate the 
amount of uric acid, and for this reason secure Ruhe- 
mann's uricometer for $2.50. Candidly, I cannot see 
any special reason for buying this instrument, dimply 
because there is very little therapeutic advantage in 



288 Essays on Laboratory Diagnosis 

knowing the amount of uric acid passed. A simple 
color test with yellow phosphomolybdic acid solution is 
sufficient, and when one knows the amounts of urea, 
ammonia and acidity, the time required to estimate uric 
acid seems to me to be wasted in ordinary routine work. 

Quantitative estimations of the phosphates, chlorides 
and sulphates may be made approximately with the nec- 
essary reagents and a test tube. (The figures may be 
made even more accurate by using the centrifuge.) 
Such tests are, of course, only comparative. One cannot 
thus estimate gravimetrically the amount of any particu- 
lar solid passed, but if one is able to find out if, for 
example, the chlorides are noticeably increased or the 
phosphates much diminished, the information will be of 
just as much value as though it were expressed in 
grammes or milligrammes. 

It will have been noted that the suggestions made in 
this article have been relative to instruments, reagents 
and equipment. Nothing is said here regarding the es- 
sential tests. It may be well to state that the manu- 
script for a book to be entitled "The Physician's Office 
Laboratory" is practically complete, and this book is to* 
be published as No. 5 of the "Metabolism Series" and 
distributed to interested physicians by G. W. Carnriclc 
& Company of New York. In this book the importance 
of the various tests, the technique and the therapeutics 
suggested by the various findings will be gathered to- 
gether, and it is hoped that this book will do much to 
popularize the use of clinical laboratory methods in the 
physician's daily office routine. 



The Twenty-F ive-D ol la r Laboratory 289 

To recapitulate the following list of simple instru- 
ments will be found practically indispensable: 

1 8-inch funnel (for "sink") $0.35 

1 3-inch funnel 20 

36 test tubes 5xf/6 inches 75 

1 pipette 5 cc 25 

1 pipette 10 cc 25 

1 graduated cylinder 250 cc 75 

1 set urinometers (Squibb) 1.00 

12 small whisky glasses (instead of 

beakers) 60 

1 spirit lamp (or Bunsen burner ) 40 

1 test tube stand for 12 tubes . . .40 

100 filter papers 15 

6 jars with bases (5x1% inches) 90 

1 acidimeter 1.50 

1 albuminometer (Esbach) 50 

1 albuminometer (Harrower) 1.00 

1 Doremus ureometer 1.00 

1 indicanmeter 1.00 

1 saccharimeter 1.00 



$12.00 

Of reagents practically all can be made at home, save, 
perhaps, the decinormal soda solution. This must be 
very carefully standardized and should be obtained from 
a dependable supply house such as Sargent & Company 
of Chicago or Eimer & Amend of New York. It costs 
from $1.00 to $1.50 a liter. Several reagents are in 
common use as remedies and will not be included in this 
list. These are: 

Formalin (ammonia). 
Chloroform (indican). 



290 Essays on Laboratory Diagnosis 

Hydrogen peroxide (blood, indican, etc.). 
Alcohol (indican, reagents, etc.). 
Carbolic acid (for Ufflemann's solution). 
Silver nitrate 10% (chlorides). 

The most essential reagents are: 

Phenolphthalein 1% in 50% alcohol (in- 
dicator), 2 oz $0.35 

Dimethyl 5% aqueous solution (indicator), 

1 oz 20 

Bromine, 8 oz. (urea) 85 

Saturated (40%) sodium hydrate solution, 

1 lb. (urea) 35 

Spiegler's solution, 8 oz. (albumin) 50 

Nitric acid C. P., 4 oz. (albumin) 20 

Tsuchiya's reagent, 8 oz. (albumin) 85 

Hydrochloric acid C. P., 1 lb. (indican).. .35 

Acetic acid glacial, 4 oz 25 

Meyer's reagent, 4 oz, (blood) 75 

Haines' solution, 8 oz. (sugar) 40 

Decinormal soda solution, 1,000 cc. (acid- 
ity, etc.) 1.00 

Lugol's solution, 4 oz. (starch) 20 

Barium mixture, 8 oz. (sulphates) 30 

Magnesium mixture, 8 oz. (phosphates) . . .25 
Test papers — red and blue litmus and 

congo red 30 

Ferric chloride 10%, 1 oz. (diacetic acid). .15 
Sodium nitroprussied, %. oz. (acetone). . . .35 
Ammonia water, 8 oz. (blood, acetone, 

etc.) . 25 

Phosphomolybdic acid solution, 1 oz., 

(uric acid) .35 

$8.20 
This makes a total of about $20.00. The prices will 



The Twenty-Fivc-Dollar Laboratory 291 

vary slightly, although I am confident that the above 
figures might even be bettered if the purchasing is done 
at a supply house instead of at the corner drug store. 

Books must not be forgotten. The best two books, 
in my estimation, are Faught's ''Essentials of Labora- 
tory Diagnosis'' at $2.00 (F. A. Davis Company, Phila- 
delphia) and Saxe's "Examination of the Urine" at $1.75 
(W. B. Saunders Company, Philadelphia). 

So, you see, one can get a whole lot into a $25.00 
office laboratory, and if any reader of The World 
wants to ask any questions and has a two-cent stamp 
to enclose I shall be most happy to offer them my best 
assistance and co-operation. 

921 Schiller Bldg., Chicago. 



APR 24 19H 



One copy del. to Cat. Div. 
APR 24 I9ff 



